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
+
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
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
+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
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
+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
+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
+
A Story About a Problem
+
Too Many CAUTIs
CAUTIs1000 days
1st quarter
+
Too Many CAUTIs
CAUTIs1000 days
1st quarter
+
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
+ 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
+
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
+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
+
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
+
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
+
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
+
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
+
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
+
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
+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
+
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
+
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
+
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
+
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
+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
+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
+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
+
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
+ 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
+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
+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
+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
+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
+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
+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
+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
+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
+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
+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
+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
+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
+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
+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
+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
+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
+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
+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
+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
-
+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
-
+
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
-
+
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
-
+
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
-
+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
-
+
+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
-
+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
-
+
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
-
+ 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
-
+ 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
-
+
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
-
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
-
+
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
-
+
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
-
+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
-
+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
-
+
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
-
+
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
-
+
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
-
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
-
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
-
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
-
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
-
+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
-
+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
-
+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
-
+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
-
+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
-
+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
-
+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
-
+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
-
+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
-
+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
-
+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
-
+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
-
+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
-
+
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
-
+
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
-
+
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
-
+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
-
+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
-
+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
-
+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
-
+
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
-
+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
-
+ 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
-
+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
-
+
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
-
+
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
-
+
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
-
+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
-
+
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
-
+
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
-
+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
-
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
-
+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
-
+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
-
+
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
-
+ 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
-
+ 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
-
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
-
+ 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
-
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
-
+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
-
+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
-
+
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
-
+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
-
+ 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
-
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
-
