Qiebp research

116
+ Distinctions, Synergies, and Infrastructures to Optimize Patient Outcomes Evidence Based Practice, Research and Quality: Hedges (2006) Clinical Fellows Graduation TCU Sept 21, 2011

Transcript of Qiebp research

Page 1: Qiebp research

+

Distinctions Synergies and Infrastructures to Optimize Patient Outcomes Lisa Hopp PhD RNljhopppurduecaledu

Evidence Based Practice Research and Quality

Hedges (2006)

Clinical Fellows GraduationTCUSept 21 2011

First show of handshellip

1 I am a staff nurse

2 I am a manager or director

I am an advanced practice nurse4

7 I am having an identity crisis

I am an educator or researcher

5

3 I am a fellowrsquos mentor

I am a nurse executive

6

+Why do I ask-It matters to the

Problems you identify

Questions you ask

Alternative solutions

you generate

Solutions you choose

Another show of handsYour primary focus

1 Generating research

2 Using research

3 Using the best available evidence

Thinking in action taking care of patients

5

4 Improving process and outcomes

Other6

+Think about the last innovation that you have been involved in

Nice and neat

Fits and starts

Flexible and fluid

What did the process look like

+Why are we hereCompare 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

Describe ideal infrastructure characteristics that promote high quality patient outcomes evidence uptake and clinical inquiry mentorship

leadership

organizational culture

evaluation processes

+

A Story About a Problem

+

Too Many CAUTIs

CAUTIs1000 days

1st quarter

>

amanda1

Lisa Hopp

Lisa Hopps Podcasts

2011

12486968

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+

Key Issues

What is the problem

What is(are) the cause(s)

What is the right thing to do

What is the right way to do it

What is the right cost to do

+ Who is paying attention

+

Clinical ResearchEBPQI

ldquoKnowing is not enough we must apply Willing is not enough we must dordquo-Goethe

+Quality of Care in the US 1998-2002

Asc

h SM

Kerr

EA

Keese

y J et

al

(20

06

) W

ho is

at

gre

ate

st r

isk

for

rece

ivin

g-p

oor

qualit

y h

ealt

h c

are

N

EJM

3

54

1

14

7-5

6

Comparison

recommend care

gender women 566

men 523

age lt31 yrs 575

gt64 yrs 521

race black 576 hispanic 575

white 541

income gt$50K 566 lt15K 531

Overall 549 of participants received recommended care

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

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+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

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+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

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+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

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duct

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id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

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wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

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wjf

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pro

duct

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id

=253

51amp

c=EM

C-C

A142

or

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hpr

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rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

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duct

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id

=2

53

51

ampc=

EM

C-C

A1

42

or

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p

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ape

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ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

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wjf

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duct

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id

=253

51amp

c=EM

C-C

A142

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hpr

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d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 2: Qiebp research

First show of handshellip

1 I am a staff nurse

2 I am a manager or director

I am an advanced practice nurse4

7 I am having an identity crisis

I am an educator or researcher

5

3 I am a fellowrsquos mentor

I am a nurse executive

6

+Why do I ask-It matters to the

Problems you identify

Questions you ask

Alternative solutions

you generate

Solutions you choose

Another show of handsYour primary focus

1 Generating research

2 Using research

3 Using the best available evidence

Thinking in action taking care of patients

5

4 Improving process and outcomes

Other6

+Think about the last innovation that you have been involved in

Nice and neat

Fits and starts

Flexible and fluid

What did the process look like

+Why are we hereCompare 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

Describe ideal infrastructure characteristics that promote high quality patient outcomes evidence uptake and clinical inquiry mentorship

leadership

organizational culture

evaluation processes

+

A Story About a Problem

+

Too Many CAUTIs

CAUTIs1000 days

1st quarter

>

amanda1

Lisa Hopp

Lisa Hopps Podcasts

2011

12486968

eng - iTunNORM 00000124 00000124 000051C1 000051A0 0000A78D 0000A78D 00007E40 00007E24 0000A78D 0000A78D

eng - iTunSMPB 00000000 00000210 000008C2 000000000053FB2E 00000000 000F3783 00000000 00000000 00000000 00000000 00000000 00000000

+

Key Issues

What is the problem

What is(are) the cause(s)

What is the right thing to do

What is the right way to do it

What is the right cost to do

+ Who is paying attention

+

Clinical ResearchEBPQI

ldquoKnowing is not enough we must apply Willing is not enough we must dordquo-Goethe

+Quality of Care in the US 1998-2002

Asc

h SM

Kerr

EA

Keese

y J et

al

(20

06

) W

ho is

at

gre

ate

st r

isk

for

rece

ivin

g-p

oor

qualit

y h

ealt

h c

are

N

EJM

3

54

1

14

7-5

6

Comparison

recommend care

gender women 566

men 523

age lt31 yrs 575

gt64 yrs 521

race black 576 hispanic 575

white 541

income gt$50K 566 lt15K 531

Overall 549 of participants received recommended care

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 3: Qiebp research

+Why do I ask-It matters to the

Problems you identify

Questions you ask

Alternative solutions

you generate

Solutions you choose

Another show of handsYour primary focus

1 Generating research

2 Using research

3 Using the best available evidence

Thinking in action taking care of patients

5

4 Improving process and outcomes

Other6

+Think about the last innovation that you have been involved in

Nice and neat

Fits and starts

Flexible and fluid

What did the process look like

+Why are we hereCompare 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

Describe ideal infrastructure characteristics that promote high quality patient outcomes evidence uptake and clinical inquiry mentorship

leadership

organizational culture

evaluation processes

+

A Story About a Problem

+

Too Many CAUTIs

CAUTIs1000 days

1st quarter

>

amanda1

Lisa Hopp

Lisa Hopps Podcasts

2011

12486968

eng - iTunNORM 00000124 00000124 000051C1 000051A0 0000A78D 0000A78D 00007E40 00007E24 0000A78D 0000A78D

eng - iTunSMPB 00000000 00000210 000008C2 000000000053FB2E 00000000 000F3783 00000000 00000000 00000000 00000000 00000000 00000000

+

Key Issues

What is the problem

What is(are) the cause(s)

What is the right thing to do

What is the right way to do it

What is the right cost to do

+ Who is paying attention

+

Clinical ResearchEBPQI

ldquoKnowing is not enough we must apply Willing is not enough we must dordquo-Goethe

+Quality of Care in the US 1998-2002

Asc

h SM

Kerr

EA

Keese

y J et

al

(20

06

) W

ho is

at

gre

ate

st r

isk

for

rece

ivin

g-p

oor

qualit

y h

ealt

h c

are

N

EJM

3

54

1

14

7-5

6

Comparison

recommend care

gender women 566

men 523

age lt31 yrs 575

gt64 yrs 521

race black 576 hispanic 575

white 541

income gt$50K 566 lt15K 531

Overall 549 of participants received recommended care

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 4: Qiebp research

Another show of handsYour primary focus

1 Generating research

2 Using research

3 Using the best available evidence

Thinking in action taking care of patients

5

4 Improving process and outcomes

Other6

+Think about the last innovation that you have been involved in

Nice and neat

Fits and starts

Flexible and fluid

What did the process look like

+Why are we hereCompare 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

Describe ideal infrastructure characteristics that promote high quality patient outcomes evidence uptake and clinical inquiry mentorship

leadership

organizational culture

evaluation processes

+

A Story About a Problem

+

Too Many CAUTIs

CAUTIs1000 days

1st quarter

>

amanda1

Lisa Hopp

Lisa Hopps Podcasts

2011

12486968

eng - iTunNORM 00000124 00000124 000051C1 000051A0 0000A78D 0000A78D 00007E40 00007E24 0000A78D 0000A78D

eng - iTunSMPB 00000000 00000210 000008C2 000000000053FB2E 00000000 000F3783 00000000 00000000 00000000 00000000 00000000 00000000

+

Key Issues

What is the problem

What is(are) the cause(s)

What is the right thing to do

What is the right way to do it

What is the right cost to do

+ Who is paying attention

+

Clinical ResearchEBPQI

ldquoKnowing is not enough we must apply Willing is not enough we must dordquo-Goethe

+Quality of Care in the US 1998-2002

Asc

h SM

Kerr

EA

Keese

y J et

al

(20

06

) W

ho is

at

gre

ate

st r

isk

for

rece

ivin

g-p

oor

qualit

y h

ealt

h c

are

N

EJM

3

54

1

14

7-5

6

Comparison

recommend care

gender women 566

men 523

age lt31 yrs 575

gt64 yrs 521

race black 576 hispanic 575

white 541

income gt$50K 566 lt15K 531

Overall 549 of participants received recommended care

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 5: Qiebp research

+Think about the last innovation that you have been involved in

Nice and neat

Fits and starts

Flexible and fluid

What did the process look like

+Why are we hereCompare 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

Describe ideal infrastructure characteristics that promote high quality patient outcomes evidence uptake and clinical inquiry mentorship

leadership

organizational culture

evaluation processes

+

A Story About a Problem

+

Too Many CAUTIs

CAUTIs1000 days

1st quarter

>

amanda1

Lisa Hopp

Lisa Hopps Podcasts

2011

12486968

eng - iTunNORM 00000124 00000124 000051C1 000051A0 0000A78D 0000A78D 00007E40 00007E24 0000A78D 0000A78D

eng - iTunSMPB 00000000 00000210 000008C2 000000000053FB2E 00000000 000F3783 00000000 00000000 00000000 00000000 00000000 00000000

+

Key Issues

What is the problem

What is(are) the cause(s)

What is the right thing to do

What is the right way to do it

What is the right cost to do

+ Who is paying attention

+

Clinical ResearchEBPQI

ldquoKnowing is not enough we must apply Willing is not enough we must dordquo-Goethe

+Quality of Care in the US 1998-2002

Asc

h SM

Kerr

EA

Keese

y J et

al

(20

06

) W

ho is

at

gre

ate

st r

isk

for

rece

ivin

g-p

oor

qualit

y h

ealt

h c

are

N

EJM

3

54

1

14

7-5

6

Comparison

recommend care

gender women 566

men 523

age lt31 yrs 575

gt64 yrs 521

race black 576 hispanic 575

white 541

income gt$50K 566 lt15K 531

Overall 549 of participants received recommended care

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 6: Qiebp research

+Why are we hereCompare 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

Describe ideal infrastructure characteristics that promote high quality patient outcomes evidence uptake and clinical inquiry mentorship

leadership

organizational culture

evaluation processes

+

A Story About a Problem

+

Too Many CAUTIs

CAUTIs1000 days

1st quarter

>

amanda1

Lisa Hopp

Lisa Hopps Podcasts

2011

12486968

eng - iTunNORM 00000124 00000124 000051C1 000051A0 0000A78D 0000A78D 00007E40 00007E24 0000A78D 0000A78D

eng - iTunSMPB 00000000 00000210 000008C2 000000000053FB2E 00000000 000F3783 00000000 00000000 00000000 00000000 00000000 00000000

+

Key Issues

What is the problem

What is(are) the cause(s)

What is the right thing to do

What is the right way to do it

What is the right cost to do

+ Who is paying attention

+

Clinical ResearchEBPQI

ldquoKnowing is not enough we must apply Willing is not enough we must dordquo-Goethe

+Quality of Care in the US 1998-2002

Asc

h SM

Kerr

EA

Keese

y J et

al

(20

06

) W

ho is

at

gre

ate

st r

isk

for

rece

ivin

g-p

oor

qualit

y h

ealt

h c

are

N

EJM

3

54

1

14

7-5

6

Comparison

recommend care

gender women 566

men 523

age lt31 yrs 575

gt64 yrs 521

race black 576 hispanic 575

white 541

income gt$50K 566 lt15K 531

Overall 549 of participants received recommended care

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 7: Qiebp research

+

A Story About a Problem

+

Too Many CAUTIs

CAUTIs1000 days

1st quarter

>

amanda1

Lisa Hopp

Lisa Hopps Podcasts

2011

12486968

eng - iTunNORM 00000124 00000124 000051C1 000051A0 0000A78D 0000A78D 00007E40 00007E24 0000A78D 0000A78D

eng - iTunSMPB 00000000 00000210 000008C2 000000000053FB2E 00000000 000F3783 00000000 00000000 00000000 00000000 00000000 00000000

+

Key Issues

What is the problem

What is(are) the cause(s)

What is the right thing to do

What is the right way to do it

What is the right cost to do

+ Who is paying attention

+

Clinical ResearchEBPQI

ldquoKnowing is not enough we must apply Willing is not enough we must dordquo-Goethe

+Quality of Care in the US 1998-2002

Asc

h SM

Kerr

EA

Keese

y J et

al

(20

06

) W

ho is

at

gre

ate

st r

isk

for

rece

ivin

g-p

oor

qualit

y h

ealt

h c

are

N

EJM

3

54

1

14

7-5

6

Comparison

recommend care

gender women 566

men 523

age lt31 yrs 575

gt64 yrs 521

race black 576 hispanic 575

white 541

income gt$50K 566 lt15K 531

Overall 549 of participants received recommended care

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 8: Qiebp research

+

Too Many CAUTIs

CAUTIs1000 days

1st quarter

>

amanda1

Lisa Hopp

Lisa Hopps Podcasts

2011

12486968

eng - iTunNORM 00000124 00000124 000051C1 000051A0 0000A78D 0000A78D 00007E40 00007E24 0000A78D 0000A78D

eng - iTunSMPB 00000000 00000210 000008C2 000000000053FB2E 00000000 000F3783 00000000 00000000 00000000 00000000 00000000 00000000

+

Key Issues

What is the problem

What is(are) the cause(s)

What is the right thing to do

What is the right way to do it

What is the right cost to do

+ Who is paying attention

+

Clinical ResearchEBPQI

ldquoKnowing is not enough we must apply Willing is not enough we must dordquo-Goethe

+Quality of Care in the US 1998-2002

Asc

h SM

Kerr

EA

Keese

y J et

al

(20

06

) W

ho is

at

gre

ate

st r

isk

for

rece

ivin

g-p

oor

qualit

y h

ealt

h c

are

N

EJM

3

54

1

14

7-5

6

Comparison

recommend care

gender women 566

men 523

age lt31 yrs 575

gt64 yrs 521

race black 576 hispanic 575

white 541

income gt$50K 566 lt15K 531

Overall 549 of participants received recommended care

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 9: Qiebp research

+

Key Issues

What is the problem

What is(are) the cause(s)

What is the right thing to do

What is the right way to do it

What is the right cost to do

+ Who is paying attention

+

Clinical ResearchEBPQI

ldquoKnowing is not enough we must apply Willing is not enough we must dordquo-Goethe

+Quality of Care in the US 1998-2002

Asc

h SM

Kerr

EA

Keese

y J et

al

(20

06

) W

ho is

at

gre

ate

st r

isk

for

rece

ivin

g-p

oor

qualit

y h

ealt

h c

are

N

EJM

3

54

1

14

7-5

6

Comparison

recommend care

gender women 566

men 523

age lt31 yrs 575

gt64 yrs 521

race black 576 hispanic 575

white 541

income gt$50K 566 lt15K 531

Overall 549 of participants received recommended care

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 10: Qiebp research

+ Who is paying attention

+

Clinical ResearchEBPQI

ldquoKnowing is not enough we must apply Willing is not enough we must dordquo-Goethe

+Quality of Care in the US 1998-2002

Asc

h SM

Kerr

EA

Keese

y J et

al

(20

06

) W

ho is

at

gre

ate

st r

isk

for

rece

ivin

g-p

oor

qualit

y h

ealt

h c

are

N

EJM

3

54

1

14

7-5

6

Comparison

recommend care

gender women 566

men 523

age lt31 yrs 575

gt64 yrs 521

race black 576 hispanic 575

white 541

income gt$50K 566 lt15K 531

Overall 549 of participants received recommended care

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 11: Qiebp research

+

Clinical ResearchEBPQI

ldquoKnowing is not enough we must apply Willing is not enough we must dordquo-Goethe

+Quality of Care in the US 1998-2002

Asc

h SM

Kerr

EA

Keese

y J et

al

(20

06

) W

ho is

at

gre

ate

st r

isk

for

rece

ivin

g-p

oor

qualit

y h

ealt

h c

are

N

EJM

3

54

1

14

7-5

6

Comparison

recommend care

gender women 566

men 523

age lt31 yrs 575

gt64 yrs 521

race black 576 hispanic 575

white 541

income gt$50K 566 lt15K 531

Overall 549 of participants received recommended care

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 12: Qiebp research

+Quality of Care in the US 1998-2002

Asc

h SM

Kerr

EA

Keese

y J et

al

(20

06

) W

ho is

at

gre

ate

st r

isk

for

rece

ivin

g-p

oor

qualit

y h

ealt

h c

are

N

EJM

3

54

1

14

7-5

6

Comparison

recommend care

gender women 566

men 523

age lt31 yrs 575

gt64 yrs 521

race black 576 hispanic 575

white 541

income gt$50K 566 lt15K 531

Overall 549 of participants received recommended care

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 13: Qiebp research

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 14: Qiebp research

+

IOM Knowing What Works in Healthcare (2008)RWJ commissioned IOM to

ldquoRecommend a sustainable replicable approach to identifying effective clinical servicesrdquo

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

httpwwwrwjforgprproductjspid=25351ampc=EMC-CA142 or httpwwwnapeducatalogphprecord_id=120388

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 15: Qiebp research

+

Research Gaps Duplications and Contradictions

IOM 2008

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 16: Qiebp research

+

Paying Attention

10 Nurse-Hospital Acquired Conditions

High cost high volume higher

payment and ldquocould reasonably have been prevented through the application of evidence based guidelinesrdquo

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 17: Qiebp research

+

Paying Attention

Habit

Active feedback

No one excused

Data driven

Systems

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 18: Qiebp research

+

Paying Attention

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 19: Qiebp research

+IOM Roundtable on EBMrsquos 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 evidencehellipthe 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

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 20: Qiebp research

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 21: Qiebp research

+

2010 Affordable Care Act

ldquonon-profit organization to

assist patients clinicians purchasers and policy- makers in making informed health decisions by carrying out

research projects that provide quality relevant

evidence on how diseases disorders and other health

conditions can effectively and appropriately be prevented diagnosed treated monitored and managedrdquo (GAO 2010)

PCORIPatient-Centered Outcomes Research Institute

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 22: Qiebp research

+

2010 Affordable Care Act Increased emphasis

on systematic review as a method to

compare effectiveness of

treatments

PCORIPatient-Centered Outcomes Research Institute

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 23: Qiebp research

+

ldquoHuman responses include any observable need concern condition event or fact of interest to nurses that may be the target of evidence-based practicerdquo (p 10)

ANA Social Policy Statement (2010)

First time that EBP is explicit in the statement that defines our social obligation to patients

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 24: Qiebp research

+ANA Social Policy Statement (2010)ldquoNursing actions are theoretically derived evidence-based and require well-developed intellectual competenciesrdquo (p11)

ldquoAssurance of safe quality and evidence-based practicerdquo (p 19)

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 25: Qiebp research

+Defining Characteristics of Nursing Practice

Human Responses

(Phenomena)

Theory Application(Science)

Nursing Actions(EBP)

Outcomes(effects)

ANA Social Policy Statement (2010) p 11

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 26: Qiebp research

+Magnettrade Recognition

Research EBP and

QI

Infrastructure

Infrastructure

Process outcomes

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 27: Qiebp research

+

EBP and Quality go hand-in-hand

IOM

CMS

AHRQ

JC

ANA

ANCC

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 28: Qiebp research

+ Distinctions

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 29: Qiebp research

+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 46102(d)

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 30: Qiebp research

+Key Questions

What is the effecthellip

What is the experiencehellip

What is the relationshiphellip

Etchelliphellip

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 31: Qiebp research

+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

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 32: Qiebp research

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 33: Qiebp research

+Defining evidence-based nursing practice

ldquoThe process by which nurses make clinical decisions using the best available research evidence their clinical expertise and patient preferences in the context of available resourcesrdquo

DiCenso Cullum and Ciliska (1998) Implementing evidence based practice Some misconceptions Evidence Based Nursing 1 38-41

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 34: Qiebp research

+Implications of the Definition

bull Bestbull Available

Evidence

bull Criteriabull Externalized

Clinical Expertise bull Meaning of

experiencesbull Individualized

Patient Preferences

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 35: Qiebp research

+Best Available

Best bull Right

evidence for the question

bull Pre-appraised

bull Standard Appraisal Tools

Availa

ble bull Sourcesbull Techniquebull Exhaustive

Feasi

ble bull Accessibl

ebull User-

friendlybull Relevant

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 36: Qiebp research

+The Nature of Evidence (1996)

Shift toward pluralistic inclusive definitions of what evidence is and subsequently of what evidence based practice is

(Pearson et al 2005)

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 37: Qiebp research

+Reconceptualizing Evidence

From experience

From acknowledged experts

From learnedofficial bodies

From experimental research

From any rigorous research studies

About feasibility appropriateness meaningfulness and effectiveness

Evidence =

knowledge arising

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 38: Qiebp research

+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 amp Howarth 2007

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 39: Qiebp research

+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 amp Haynes 1995)

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 40: Qiebp research

+Quality Improvement

Systematic data-driven process that teams use to improve systems processes and outcomes

Generally conducted locally though maybe organized at larger levels

Lean methods aim to eliminate waste

Six Sigma aims to eliminate defects

Newhouse 2007

ldquoObsessed with failurerdquo

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 41: Qiebp research

+Key Questions in QI

Do you know how good you are

Do you know where you stand relative to the best

Do you know where the variation exists

Do you know your rate of improvement over time

Maureen Bisognano CEO IHI

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 42: Qiebp research

+Essential Steps in QI agrave 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)

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 43: Qiebp research

+Problem-Solving

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 44: Qiebp research

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling catheters

Conducted clinical research

>

amanda2research

Lisa Hopp

Lisa Hopps Podcasts

2011

107026306

eng - iTunNORM 0000017B 0000017B 00004A0A 000049EE 00016DD0 00016DD0 00007E8E 00007E72 00016DB6 00016DB6

eng - iTunSMPB 00000000 00000210 00000742 000000000047FB2E 00000000 000D09F6 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 45: Qiebp research

+How would the story go if Amandahellip

What is the effect of nursing stop-orders vs usual physician orders on reinsertion rates catheter days and incidence of CAUTIs in uncomplicated non-urinary surgical patients with short term indwelling cathetersWas involved in

an evidence implementation project

>

amanda3EBP

Lisa Hopp

Lisa Hopps Podcasts

2011

13526743

eng - iTunNORM 0000013E 0000013E 0000470B 000046F0 000055B6 000055B6 00007EF4 00007EDE 0000559C 0000559C

eng - iTunSMPB 00000000 00000210 000007C2 00000000005AFB2E 00000000 00107C69 00000000 00000000 00000000 00000000 00000000 00000000

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 46: Qiebp research

+How would the story go if Amandahellip

Catheter days and incidence of CAUTIs in surgical patients with short term indwelling catheters are too high

Was involved in a QI project

>

amanda4QI

Lisa Hopp

Lisa Hopps Podcasts

2011

7583305

eng - iTunNORM 000000ED 000000ED 00003D5A 00003D45 0000E634 0000E634 00007E77 00007E5F 0000E61A 0000E61A

eng - iTunSMPB 00000000 00000210 00000A42 000000000032FB2E 00000000 00093B44 00000000 00000000 00000000 00000000 00000000 00000000

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 47: Qiebp research

+How did these stories compare

Research EBP QI

Goal Grow knowledge for better pt outcomes

Close gap between know and do for best pt outcomes

Best patient outcomes best cost and regulatory compliance

Relationship with knowledge

Generate or confirm new knowledge

Synthesize translate and use knowledge

Systematically optimize how to process knowledge

Time required

Longest but variable

Longer but variable

Aim for rapid but variable

Designs Quant to qual Before-after with process monitor

Before-after with process monitor

Key Differences

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 48: Qiebp research

+How did these stories compare

Research EBP QI

IRB required Yes Sometimes Not usually

Flexibility Dependent upon design-varies from rigid to more fluid

Dependent upon approach but generally fluid

Generally fluid and locally driven

Funding Often external Usually internal maybe external

Part of usual operational funding

Time to Impact

Long term Short term Short term to immediate

Key Differences

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 49: Qiebp research

+

Key Similarities

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

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

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 50: Qiebp research

+

Are there hazards when QI=RU

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 51: Qiebp research

+

Target 80-110 mgdL

The Intensive

Insulin Therapy

Story

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 52: Qiebp research

+Intensive Insulin Tx

Leuven Trial-2001

Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc gt 215 mgdL) and intensive (IV insulin to maintain glc 80-110 mgdL)

Findings IIT reduced mortality morbidity in critically ill surgery patients

Van den Berghe G et al (2001) NEJM 345 1359-1367

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 53: Qiebp research

+

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 54: Qiebp research

+Practice changed

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 55: Qiebp research

+

ldquoTight glycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutritionrdquo

Marik PE amp Preiser J (2010) Chest 137 (3)

Hold on-Meta-analysis (2010)

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 56: Qiebp research

+ Hold on-Meta-analysis (2010)7 RCTs pooled with 11425 pts

IIT did notReduce 28-day mortality (OR=95

[CI 87-105]Reduce BSI (OR=104 [CI 93-117]Reduce renal replacement tx (OR=101

[CI 89-113]

IIT didIncrease hypoglycemic incidents

(OR=77 [CI 60-99] Marik PE amp Preiser J (2010) Chest 137 (3)

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 57: Qiebp research

+ 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

Mortality lower in control (glc 150 mgdl) OR=9 [CI 81-99] when Leuven trials removed

No evidence to support IIT in general med-surg ICU pts fed according to current guidelines (ie enteral) Marik PE amp Preiser J (2010)

Chest 137 (3)

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 58: Qiebp research

+

Are there hazards when QI waits on EBP

hw

ww

flic

krc

om

photo

sare

nam

onta

nus

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 59: Qiebp research

What is the ldquoideal bestrdquo type of research evidence

Comparing Treatments Meta-analysis or systematic review of RCTs

Determining extent of risk predictive of future problem

Systematic review of cohort case-control studies

Specificitysensitivity of an assessmenttest

Systematic review of blinded comparison of test and reference value

Perceptionsvaluesbeliefs

Meta-syntheses of qualitative studiesD

iCen

so G

uyat

t amp C

ilisk

a (2

005)

Cra

ig amp

Sm

yth

(20

02)

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 60: Qiebp research

+

Back to our storyhellip

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 61: Qiebp research

+

Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

0

1

2

3

4

5

6

7 CAUTIs Jan 08 - June 09

Title

Average

33110

Rate at Audit 2 281000 cath days

Pre-intervention

AF 1 AF

2

Rate at Audit 1 591000 cath days

QI effort-implementing the evidence from SRs and using evidence-based strategies

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 62: Qiebp research

+How has QI been studied for its effectiveness

Research methods are ldquoweakrdquo 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 causeeffect claims Inadequate monitoring of the intervention Self-selection bias prevalent Complex interventions Alexander et al (2009) Med

Care Res and Rev 66 235-271

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 63: Qiebp research

+Caveats

Most of 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 66 235-271

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 64: Qiebp research

+

What do you think of this statement

ldquoAll three approaches have an important yet different relationship with knowledge Research generates it EBP translates it QI incorporates itrdquo

Shirey et al 2011 J Cont Ed in Nursing 42(2)

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 65: Qiebp research

+

Synergies

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)

Tools that work for the common goal of evidence translation practice developed evidence

Enhanced point of care KT through changes in evidence transfer

Evidence-based implementation strategies

Harvey G (2005) Worldviews second quarter 52-4

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 66: Qiebp research

+

How about a shift in paradigm

Evidence-based Quality Improvement

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 67: Qiebp research

Research EBP

QI

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 68: Qiebp research

Research EBP

QI

E-B QI

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 69: Qiebp research

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 70: Qiebp research

ldquoReliable 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 usersrdquoKitson A amp Bisby M (2008)

Speeding the spread KT08

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 71: Qiebp research

+Themes for ldquohowrdquo

Shift in knowledge production from Mode 1 to Mode 2 research paradigms to ldquospeed the spreadrdquo of research evidence

Theoretical models related to ldquohowrdquo are needed some are evolving

Beyond barriers to Knowledge Translation (KT)

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 72: Qiebp research

+Mode 1 ResearchldquoBlue skyrdquoCuriosity drivenTakes place in the bench lab or clinical labTraditional linearEnd of grant transfer

Researchers generate research

questions and methods

Researchers conduct data collection

Researchers disseminate findings

at the end of the study (amongst themselves)

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 73: Qiebp research

+Mode 2 ResearchSocially distributed knowledgeNegotiationcollaboration drivenTakes place within context of applicationTransdisciplinaryReflexive dialogue iterative

Kit

son

amp B

isby 2

008)

ww

wk

usp

ualb

ert

ac

aK

T08docu

ments

cfm

Researchers

Users Multidisciplines

New Methods

and quality

Transaction-

focused

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 74: Qiebp research

+Models are Emerging

Knowledge-to-Action

PARIHS

wwwcihr-irscgccae29418html

Evidence

Context

Facilitation

SI = f (E C F)Kitson amp Bisby ( 2008)

wwwkuspualbertacaKT08documentscfm

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 75: Qiebp research

+What are common themes and characteristics among these models that can guide implementation science

Engagement

Transactional

Nonlinear

Iterative

Fuzziness

Social

Contingent

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 76: Qiebp research

+How do you do get evidence into practice

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

Emerging Science Knowledge Translation (KT)

httpwwwcihr-irscgccae29418html

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 77: Qiebp research

+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 systemhttpwwwcihr-irscgccae29418html

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 78: Qiebp research

+6 Opportunities for KT (CIHR 2005)

ResearchersKnowledge

Users

Questions amp Methods

Research Findings

Global Knowledge

Publications

Contexualization of Knowledge

Application of Knowledge

Impacts

KT1 KT2

KT3

KT4

KT5

KT6

As cited in Sudsawad P (2007) httpwwwncddrorgktproductsktintro

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 79: Qiebp research

+6 Opportunities for KT (CIHR as cited in Sudsawad 2009)

1 Defining research questionsmethods

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 useAs cited in Sudsawad P (2007)

httpwwwncddrorgktproductsktintro

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 80: Qiebp research

+KT in the US

T1-bench to clinical research

T2-clinical research to practice

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 81: Qiebp research

+What evidence exists to support getting and sustaining evidence implementation

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 82: Qiebp research

+Strategies that work betterReminders cuesEducational outreachInteractive educationDidactic continuing education meetings -small effect on professional practice and less on patient outcomes

Bero et al BMJ (1998) Grimshaw et al Cochrane Library(2005) Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 83: Qiebp research

+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 interventionsBero et al BMJ (1998) Grimshaw et al Cochrane Library(2005)

Forsetland et al (2009) Cochrane Library Farmer et al Cochrane Library (2008)

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 84: Qiebp research

+

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

Strategies that may not work

Cheater et al Cochrane Database of Reviews 2005

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 85: Qiebp research

+

Evidence of Effectiveness of Common QI Efforts

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 86: Qiebp research

+

Jamtvedt The Cochrane Library Vol3 2006 last update 506

72 studies making 88 comparisons vs no tx

10 decrease to 68 increase (continuous vars)

Low baseline compliance and higher intensity feedback associated with greater effectiveness

Risk difference ranged from 16 decrease to 70 increase in compliance (dichotomous vars)

Audit and Feedback on Compliance with Recommended Practice

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 87: Qiebp research

+VA experience with AF-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 19

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 88: Qiebp research

+Other lessons learned from QUERI

The doing 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)

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 89: Qiebp research

+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 435

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 90: Qiebp research

+Tools and Infrastructure

HumanTechnological

Contextual

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 91: Qiebp research

+

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 evidencehellipthe 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

IOM Roundtable on EBM Goal

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 92: Qiebp research

+IOMrsquos goal based onLearning health system-evidence generated and applied as a natural product of the care process

Expanding comparative effectiveness evidence capacity

Improve public understanding of the nature of evidence the dynamic nature of evidence development and the importance of insisting that care reflects the best evidence

IOM

(2011

)Learn

ing W

hat

Work

sIn

frast

ruct

ure

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 93: Qiebp research

+ IOM Themes on Infrastructure

Infrastructure for Learning

Learning beyond bridging the research

practice gapCoordinating work and ensuring standards

Planning builds to future needs

HIT investment for real-time

learning

Real-time data analysis

Trained workforce for evidence stewardshipGlobalizing

evidence and localizing decisions

Public-private capacities fuel effort

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 94: Qiebp research

+Human

Facilitation

Mentors

Communities of practice

Communication

Relationship building

Organizational Culture

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 95: Qiebp research

+

bullTraditional command control leadershipbullLack of role clarity teamworkbullPoor organizational structurebullAutocratic decision-making

bullTransformational leadershipbullClear roles effective team workbullEffective organizational structurebullDemocratic enablingempowering approaches

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Leadership

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 96: Qiebp research

+

bullUnclear values amp beliefsbullTask drivenbullLow regard for individualsbullLack of consistencybullResources not allocated

bullClear valuesbeliefsbullValues individuals consistencybullEmphasis on relationshipsbullResources allocated

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Culture

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 97: Qiebp research

+

bullAbsence ofbull Audit and feedbackbull Peer reviewbull External audit

bullNarrow use of performance information sources

bullInternal measures used routinelybullAudit and feedback used routinelybullPeer reviewbullExternal measuresbullMultiple methods

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Evaluation

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 98: Qiebp research

+Facilitation-Mentorship

Enabling others

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 99: Qiebp research

+

Task-centeredDoing for othersbullEpisodic contactbullPracticaltechnical helpbullDidactic traditional approachesbullExternal agentsbullLow intensity-extensive coverage

Holistic- orientedEnabling othersbullSustained partnershipbullDevelopmentalbullAdult learning approachesbullInternalexternal agentsbullHigh intensity-limited coverage

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Purpose and Role

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 100: Qiebp research

+

Taskdoing forbullProject management skillsbullTechnical skillsbullMarketing skillsbullSubjective technicalclinical credibility

HolisticenablingbullCo-counselingbullCritical reflectionbullGiving meaningbullFlexibility of rolebullAuthenticity

PARIHS model Rycroft-Malone (2004) Kitson et al (2008)

Skills and Attributes

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 101: Qiebp research

+Information Technology

POC Access

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 102: Qiebp research

ldquoIn 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 knowledgerdquo

Sir Muir Gray Chief Knowledge Officer of NHS-UK

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 103: Qiebp research

+Knowledge ManagementAggregate Put all your information sources in one place it auto-updates and you can share it NetVibes iGoogle

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 104: Qiebp research

+Knowledge Transfer

httpplusmcmastercanpDefaultaspx

httpwwwtropikanetsvcspecialsKT-ToolkitpagesKT-Toolkit

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 105: Qiebp research

+

Acquire

Where do you go first to find the best available evidence

How do you usually seek the evidence

Do you have Internet access at the POC

What kinds of evidence are available at the POC

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 106: Qiebp research

+ Currently EB Clinical Guidelines in the US

Highly decentralizedNational Clearinghouse - 360 different organizations

471 guidelines related to HTN276 guidelines related to strokeBut little guidance on other topics

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 107: Qiebp research

+ Recommend single entity

Build foundation for knowing what works in health care

Set priorities Open Transparent

Establish methodologic standards for systematic reviews

Develop clinical practice guidelines Transparency Minimize biash

ttp

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 108: Qiebp research

IOMrsquos Frameworkhtt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

Research Studies

Systematic Review

ID amp assess studies

Appraise body of evidence

Synthesize

Clinical Guidelines and Recommendations

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 109: Qiebp research

+ What works needed for policy to

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=2

53

51

ampc=

EM

C-C

A1

42

or

htt

p

ww

wn

ape

duc

ata

logp

hp

reco

rd_i

d=

12

03

88

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 110: Qiebp research

Per capita

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 111: Qiebp research

+Quick Action from 2008-11

SR as method to compare

effectiveness of treatments

AHRQ Standardized Systematic

Review Methods

IOM

20112008 2009

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 112: Qiebp research

+Systematic reviews should

Identify gap between what we know and what we need to know

Concise and transparent

Contradictory findings

Provide narrative summary or pooled statistical analysis

htt

p

ww

wr

wjf

org

pr

pro

duct

jsp

id

=253

51amp

c=EM

C-C

A142

or

htt

p

ww

wn

ape

duc

ata

logp

hpr

eco

rd_i

d=

1203

88

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 113: Qiebp research

+

Patient Preferences and Implementation Science

ldquoAn important barrier to the implementation of CPG recommendations is their inability to reconcile patient preferences and values as well as social normsrdquo

Legare et al 2009 Implementation Science 4 30

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 114: Qiebp research

+How do you integrate pt preferences

Examine the source of information for publicconsumer involvement in its development

Developadopt plain language information for patientsfamily

Engage a consumer in policy development

Consider patient satisfaction scores in policy refinement

Offer patient choice at POC

No systematic approach

Other

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 115: Qiebp research

+ Lisarsquos top picks for implementation resources

Cochrane Library Effective Practice and

Organisation of Care Group (EPOC) wwwcochraneorg

CIHR funded KT Clearinghouse

httpktclearinghousecacebm

Guidelines International Network

wwwg-i-nnet

RNAOrsquos toolkit for guideline implementation

wwwrnaoorg

JBI Global Learning Centre

httpwwwgloballearningcentrejoannabriggseduau

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117
Page 116: Qiebp research

The Issue Remains Know-Do

Gap

  • Slide 1
  • First show of handshellip
  • Why do I ask-It matters to the
  • Another show of hands Your primary focus
  • Think about the last innovation that you have been involved in
  • Why are we here
  • A Story About a Problem
  • Too Many CAUTIs
  • Key Issues
  • Who is paying attention
  • Clinical Research EBP QI
  • Quality of Care in the US 1998-2002
  • IOM Knowing What Works in Healthcare (2008)
  • IOM Knowing What Works in Healthcare (2008) (2)
  • Slide 15
  • Paying Attention
  • Paying Attention (2)
  • Paying Attention (3)
  • IOM Roundtable on EBMrsquos goal
  • IOM Roundtable on EBM Goal
  • 2010 Affordable Care Act
  • 2010 Affordable Care Act (2)
  • ANA Social Policy Statement (2010)
  • ANA Social Policy Statement (2010) (2)
  • Defining Characteristics of Nursing Practice
  • Magnettrade Recognition
  • EBP and Quality go hand-in-hand
  • Distinctions
  • Clinical Research
  • Key Questions
  • Steps of Research Process
  • Defining evidence-based nursing practice
  • Defining evidence-based nursing practice (2)
  • Implications of the Definition
  • Best Available
  • The Nature of Evidence (1996)
  • Reconceptualizing Evidence
  • Key Questions in EBP
  • Essential Steps in EBP
  • Quality Improvement
  • Key Questions in QI
  • Essential Steps in QI agrave la Motorola
  • Problem-Solving
  • How would the story go if Amandahellip
  • How would the story go if Amandahellip (2)
  • How would the story go if Amandahellip (3)
  • How did these stories compare
  • How did these stories compare (2)
  • Key Similarities
  • Slide 51
  • Target 80-110 mgdL
  • Intensive Insulin Tx
  • Slide 54
  • Practice changed
  • Slide 56
  • Hold on-Meta-analysis (2010)
  • Hold on-Meta-analysis (2010) (2)
  • Slide 59
  • What is the ldquoideal bestrdquo type of research evidence
  • Back to our storyhellip
  • QI effort-implementing the evidence from SRs and using evidence
  • How has QI been studied for its effectiveness
  • Caveats
  • What do you think of this statement
  • Synergies
  • How about a shift in paradigm
  • Slide 68
  • Slide 69
  • Slide 70
  • Slide 71
  • Themes for ldquohowrdquo
  • Mode 1 Research
  • Mode 2 Research
  • Models are Emerging
  • What are common themes and characteristics among these models t
  • How do you do get evidence into practice
  • Beyond Barriers Knowledge Translation (KT)
  • 6 Opportunities for KT (CIHR 2005)
  • 6 Opportunities for KT (CIHR as cited in Sudsawad 2009)
  • KT in the US
  • What evidence exists to support getting and sustaining evidence
  • Strategies that work better
  • Strategies that work better (2)
  • Slide 85
  • Evidence of Effectiveness of Common QI Efforts
  • Slide 87
  • VA experience with AF-Quality Enhancement Research Initiative
  • Other lessons learned from QUERI
  • SR Lean Six Sigma StuderGroup Hardwiring
  • Tools and Infrastructure
  • IOM Roundtable on EBM Goal (2)
  • IOMrsquos goal based on
  • IOM Themes on Infrastructure
  • Human
  • Leadership
  • Culture
  • Evaluation
  • Facilitation-Mentorship
  • Purpose and Role
  • Skills and Attributes
  • Information Technology
  • Slide 103
  • Knowledge Management
  • Knowledge Transfer
  • Acquire
  • Currently EB Clinical Guidelines in the US
  • Recommend single entity
  • IOMrsquos Framework
  • What works needed for policy to
  • Slide 111
  • Quick Action from 2008-11
  • Systematic reviews should
  • Patient Preferences and Implementation Science
  • How do you integrate pt preferences
  • Lisarsquos top picks for implementation resources
  • Slide 117