Transcript Slide 1

Illustration of the Knowledge to Action
Process
Ian D Graham PhD
CIHR
Vice President, Knowledge Translation
and Public Outreach
KT Master Class
CLAHRC Conference
Sheffield, UK
October 5th, 2010
Learning Objectives
• To better understand the knowledge to action process
by going through a specific implementation project
• To be able to use a conceptual framework to think
through an implementation project
Knowledge, if it does not determine action, is
dead to us.
Plotinus
(Roman philosopher 205AD-270AD)
Emergency instructions for those
who are theory averse
Monitor
Knowledge
Use
Select, Tailor,
Implement
Interventions
Assess Barriers/
Supports to
Knowledge Use
KNOWLEDGE CREATION
Knowledge
Inquiry
Synthesis
Adapt
Knowledge
to Local Context
Evaluate
Outcomes
Products/
Tools
Sustain
Knowledge
Use
Identify Problem
from: Graham et al:
Lost in Knowledge
Translation: Time for a Map?
Identify, Review, http://www.jcehp.com/vol26/2601g
Select Knowledge
raham2006.pdf
The knowledge to action (K2A)
framework
 assumes a systems perspective
 falls within the social constructivist paradigm which
privileges social interaction and adaptation of
research evidence that takes local context and
culture into account
• designed to be used by a broad range of audiences
• has been widely cited: 120 in ISI Web of Knowledge,
290 in H – Harzings Publish or Perish, which picks up
the grey literature (as of Sept 24, 2010)
• has not, as yet, been tested empirically
The knowledge to action (K2A)
framework: derivation
• the set of 31 theories on which the framework is based,
can provide more specific guidance as to what needs to
be done at each phase
• each theory has been broken down into its components
and data abstraction sheets for each can be found at
http://www.iceberggrebeci.ohri.ca/research/kt_theories_db.html
• each of the component theories is mapped onto the K2A
framework
• future iterations of the framework will be informed by
feedback from the researchers and knowledge-users who
are trying to apply it.
The knowledge to action (K2A)
framework
More on the systems perspective.
• knowledge producers and users are situated within a
social system or systems that are responsive and
adaptive, although not always in predictable ways.
• the K2A process is considered iterative, dynamic, and
complex, with the boundaries between the creation and
action components are fluid and permeable.
• the action phases may occur sequentially or
simultaneously and the knowledge phases may
influence or be drawn upon during action phases.
• the cyclic nature of the process and the critical role of
feedback loops are key concepts underpinning the
framework
The knowledge to action (K2A)
framework
• the framework encompasses research based as well
as other forms of knowing such as contextual and
experiential knowledge
• both the knowledge creation and action components
can be “activated” by different stakeholders and
groups working independently of each other at
different points in time
• a key assumption underlying the framework is the
importance of appropriate relationships
The knowledge to action (K2A)
framework
• the action phases enable the framing of what needs
to be done, how, and what circumstances/conditions
need to be addressed when implementing change.
• they are not meant to replace or over ride the
component theories from which the phases were
derived.
 e.g. when addressing the barriers to knowledge use, 18 of
the 31 planned action theories had a construct dealing with
this – some with more precision and coverage than others.
• for each action phase other (non-planned action)
theories (psychological, organizational, economic,
sociological, educational, etc) may be relevant and
useful (see, for example Wensing et al., 2009 in the book)
The K2A framework:
limitations in how we drew it
• our representation of the K2A cycle suggests
circularity or a sequence of phases that need to be
taken in order
• we realize that this is not how implementation
projects unfold in “real life”.
• they are often chaotic, and move forward in an erratic
manner with continuous course corrections as the
action phases accommodate the contextual factors.
• a better representation of our framework would be
the probabilistic atomic model, where the action
phases are like electrons around the nucleus of
knowledge generation - and the contextual factors
influence where a given phase might be at a specific
time.
=
The K2A framework:
limitations in how it is represented
• the two dimensional, linear representation of the
framework might seem to preclude the possibility that
change can occur at multiple levels.
• there is nothing inherent about the framework that
would exclude its use at multiple levels.
• Ferlie et al. confirm non-linear models of innovation
spread. They argue that there is no linear flow or
prescribed sequence of stages.
“Indeed, flow is a radically inappropriate image to
describe what are erratic, circular or abrupt
processes, which may come to a full stop or go into
reverse”
Ferlie et al page 123
.
Ferlie, E., Fitzgerald, L., Wood, M., & Hawkins, C. (2005). The
nonspread of innovations: The mediating role of professionals.
Academy of Management Journal, 48, 117-134.
The knowledge to action (K2A)
framework
• The framework has become a key part of messaging
about knowledge translation at CIHR since
September, 2007.
• It has been presented to a variety of CIHR’s
stakeholders and internal staff, and has been well
received in the sense that it is understandable and
relatively simple, yet comprehensive.
• Feedback from researchers and knowledge-users
suggests that it provides a useful way of thinking
about knowledge translation but more importantly, by
breaking the process into manageable piece,
provides a structure and rationale for activities.
Knowledge to action:
a personal example
•
•
•
•
•
Community care of venous leg ulcers
Collaborative interdisciplinary approach
Co-PI Dr. Margaret Harrison, Queen’s University
6 year program of research and implementation
Integrated Knowledge Translation approach
• A community-researcher alliance to improve chronic
wound care
• CIHR KT Casebook, (Graham et al, 2006)
• http://www.cihr-irsc.gc.ca/e/30669.html
Venous Leg Ulcers
Population with Leg Ulcers in particular:
 Common, costly, complex
 Chronic, recurring
 Debilitating, isolating condition
 80% care reported to be community-based,
delivered by nurses
A Picture is Worth a 1,000 Words
Monitor
Knowledge
Use
Select, Tailor,
Implement
Interventions
Assess Barriers/
Supports to
Knowledge Use
KNOWLEDGE CREATION
Knowledge
Inquiry
Synthesis
Adapt
Knowledge
to Local Context
Evaluate
Outcomes
Products/
Tools
Identify Problem
Identify, Review,
Select Knowledge
Sustain
Knowledge
Use
Monitor
Knowledge
Use
Identify Problem
Select, Tailor,
Implement
Interventions
KNOWLEDGE CREATION
Evaluate
Outcomes
Knowledge Inquiry
Identify, Review,
Select Knowledge
Assess
Barriers to
Knowledge Use
Adapt
Knowledge
to Local Context
Synthesis
Products/
Tools
Sustain
Knowledge
Use
Identify Problem
Identify, Review,
Select Knowledge
• Homecare authority identified costs associated with leg
ulcer care as an issue
• Formed an alliance between decision-makers,
clinicians (and researchers) for planning, and to design
and conduct a needs assessment
Knowledge
Inquiry
Knowledge Inquiry
Synthesis
Products/
Tools
Identifying the Problem
Worked with the health authority and nursing
agencies to understand the local:
• Population
• Providers, scopes of practice
• Practice environment
• Gaps re: evidence-based practice
Conducted Preliminary Studies
Regional prevalence & profile study
• Prevalence: 1.8/1000 population (> 25 years)
• 3/4 were > 65 years
• Majority independently mobile
• 60% had 4 or more co-morbid conditions
• Recurrent - 64% had a recurrent venous ulcer
• Longstanding - 60% had ulcer > 6 months, 1/3 >1 year
• 40% had 2 or more ulcers
Environmental scan, expenditures
• Average 19 different nurses saw any one client in month
• 40% received daily or twice a day visits
• 4 week costing estimated 192 cases $1.26 million nursing &
supply expenditures
(Harrison, et al 2001; Lorimer, et al 2003; Nemeth, et al 2003, 2004; Friedberg, et al
2002)
Knowledge
Inquiry
Synthesis
Synthesis
Products/
Tools
Identifying the problem
•Systematic review of incidence/prevalence studies
Monitor
Knowledge
Use
Identify Problem
Identify, Review,
Select Knowledge
Select, Tailor,
Implement
Interventions
Assess
Barriers to
Knowledge Use
KNOWLEDGE CREATION
Knowledge
Inquiry
Synthesis
Adapt
Knowledge
to Local Context
Evaluate
Outcomes
Products/
Tools
Sustain
Knowledge
Use
Identify Problem
Identify, Review,
Select Knowledge
• High level evidence for assessment and management
of venous ulcers available (numerous RCTs, Cochrane
Systematic Review)
• Numerous international Clinical Practice Guidelines
available
Monitor
Knowledge
Use
Adapt
Knowledge to
Local Context
Select, Tailor,
Implement
Interventions
Evaluate
outcomes
Assess
Barriers to
Knowledge Use
Sustain
Knowledge
Use
Adapt
Knowledge
to Local Context
Identify Problem
Identify, Review,
Select Knowledge
10. Scheduled Review and
Revision of Local Guideline
1. Identify a Clinical Area to
Promote Best Practice
9. Official Endorsement
and Adoption of Local
Guideline
2. Establish an
Interdisciplinary Guideline
Evaluation Group
8. Finalize Local Guideline
3. Establish Guideline
Appraisal Process
7. External Review – Practioner
and Policy Maker Feedback;
Expert Peer Review
4. Search and Retrieve
Guidelines
6. Adaptation of
Guidelines for Local Use
5. Guidelines Assessment
a) Quality
b) Currency
c) Content
Practice Guidelines Evaluation and Adaptation Cycle
(Graham et al 1999; Graham et al 2005)
Practice Guideline Evaluation and
Adaptation Cycle
The framework has been used by numerous groups
• Canadian Strategy for Cancer Control
• Canadian Stroke Network
• Canadian Stroke Strategy
• Ottawa Hospital
• CIHR grant
Foundational component of the international ADAPTE
process
•
www.adapte.org
Ottawa-Carleton CCAC Leg Ulcer Care Protocol Reference Guide
1. Assessment
Clinical history, physical exam and lab testing to assess etiology and factors
1, 3, 4, 6, 7
C
contributing to the leg ulcer
1-4, 6, 7
Ankle Brachial Pressure Index (ABPI) to screen for arterial disease
A
2.3 Venous
ABPI at least 0.8 6,7
Absence of arterial and other
non-venous disease
3. Management
of Leg Ulcer
4.Wound
Management
5. If ulcer is
Painful
6. If no sign of
infection
7. If ulcer is
associated with
dermatitis
8. If ulcer is
unhealed after 12
weeks of active
treatment
9. If ulcer has
healed
C
2.1 Non-Venous or Mixed 1-3, 6, 7
ABPI between 0.5 and 0.8
OR
Unusual ulcer presentation
OR
Presence of other disease
Refer to the appropriate specialist1
C
Graduated, multilayer compression bandaging for the
uncomplicated ulcer. High compression (35-40 mm Hg)
is more effective than low compression. 1- 7
Applied by trained practitioner 1-7
Measure surface area serially over time. 1-3, 6
Wash ulcer with tap water or saline 1, 2, 4, 6
Simple non-adherent dressing 1-3, 6
Acceptable to client 1
Dressing appropriate to stage of healing and
amount of exudate. 4
Moist wound environment 4-7
Hydrocolloid or foam dressing 2
Pain management plan: 1, 3, 4, 6, 7
Compression, exercise, elevation and analgesia
No routine bacteriological swab
2.2 Arterial
ABPI less
than 0.5
Refer to
Vascular
surgeon 1-4, 6-8
A
B
B
C
A
C
C
A
A
1, 3, 4, 6, 7
1-3, 5, 6
A
Refer for patch skin testing. 1-3, 6
Avoid products that commonly cause skin sensitivity
e.g. lanolin,1 topical antibiotics 1-3, 6
Repeat ABPI 1, 2, 6
Review diagnosis, management and client adherence
with treatment; may require specialist referral and/or
biopsy 2-4
Compression stockings (fitted) 1-3, 5, 6
Prevention of Recurrence: Client Education3, 4, 6
skin care, 1-3, 6 exercise, 1-4, 6, 7 elevation of legs 1,
C
B
B
B
C
A
2, 6, 7
C
Monitor
Knowledge
Use
Assess
Barriers/supports to
Knowledge Use
Select, Tailor,
Implement
Interventions
Evaluate
outcomes
Assess
Barriers to
Knowledge Use
Sustain
Knowledge
Use
Adapt
Knowledge
to Local Context
Identify Problem
Identify, Review,
Select Knowledge
Approach to barriers assessment included:
• Knowledge, attitudes and practice (KAP) surveys of
nurses and physicians (barriers to the guideline)
• Practitioner/policy maker feedback on adapted care
protocol (barriers to the potential adopters)
• Discussions with providers and managers (barriers in the
practice environment)
(Graham, Harrison, Friedberg et al. 2001; Graham, Harrison, Shafey et
al. 2003)
Monitor
Knowledge
Use
Assess
Barriers/supports to
Knowledge Use
Select, Tailor,
Implement
Interventions
Evaluate
outcomes
Assess
Barriers to
Knowledge Use
Sustain
Knowledge
Use
Adapt
Knowledge
to Local Context
Identify Problem
Identify, Review,
Select Knowledge
• Knowledge deficits about effective treatment
(compression bandaging)
• Lack of skills to assess for venous disease, bandage
application
• Lack of dopplers
• Staffing system for community nursing agency
• Referral system (GP->home care; nurses>specialists)
• Remuneration system for nursing agencies
• Positive attitudes toward care of individuals with leg
ulcers
•Nurses better knowledge of than others
Monitor
Knowledge
Use
Select, Tailor,
Implement
Interventions
Select, Tailor,
Implement
Interventions
Evaluate
outcomes
Assess
Barriers to
Knowledge Use
Sustain
Knowledge
Use
Adapt
Knowledge
to Local Context
Identify Problem
Identify, Review,
Select Knowledge
Interventions for implementation
Provider level
Training for nurses (UK N18 course, doppler & bandaging
training)
Practice setting level
Redesigned service delivery for EB leg ulcer care
 dedicated RN leg ulcer care team
 home and clinic
 equipment
 reimbursement alterations
 changes to process for referral to
specialists
Monitor
Knowledge
Use
Select, Tailor,
Implement
Interventions
Select, Tailor,
Implement
Interventions
Evaluate
outcomes
Assess
Barriers to
Knowledge Use
Sustain
Knowledge
Use
Adapt
Knowledge
to Local Context
Identify Problem
Identify, Review,
Select Knowledge
Developed tools to facilitate use of the
recommendations
 Protocol algorithm (knowledge
tool/adaptation/intervention)
 Assessment and documentation tools
Monitor
Knowledge
Use
Evaluate
outcomes
Synthesis
KNOWLEDGE CREATION
Adapt
Knowledge
to Local Context
Knowledge
Inquiry
Assess
Barriers to
Knowledge Use
Products/
Tools
Monitor
Knowledge
Use
Select, Tailor,
Implement
Interventions
Sustain
Knowledge
Use
Identify Problem
Recommendations
Uptake
Identify, Review,
Select Knowledge
Pre guideline
adoption
(n = 66)
Post Guideline adoption
(n = 238)
n (%)
n (%)
Identification of Ulcer
Etiology
35 (53)
238 (100)
ABPI prior to initiating
compression
21 (47)
227 (95)
Serial Ulcer measurement
recorded
7 (11)
80(88)
Compression bandage
initiated for venous ulcers
44 (66)
148 (86)
Pain Assessment
Documented
10 (15)
215 (90)
Parameters of EBCPG
Select, Tailor,
Implement
Interventions
Evaluate
Outcomes
Monitor
Knowledge
Use
Evaluate
Outcomes
Assess
Barriers to
Knowledge Use
Sustain
Knowledge
Use
Adapt
Knowledge
to Local Context
Identify Problem
Identify, Review,
Select Knowledge
Pre-post Evaluation of Outcomes
(Harrison, Graham, Lorimer et. al CMAJ 2005)
• 3 month healing rate: 23% → 56%
• Nursing Visits
– median 3 → 2.1/wk
– daily visiting decreased from 38% → 6%
• Supply costs
– Median per case: $1923 → $406
Monitor
Knowledge
Use
Sustain
Knowledge
Use
Select, Tailor,
Implement
Interventions
Evaluate
Outcomes
Assess
Barriers to
Knowledge Use
Sustain
Knowledge
Use
Adapt
Knowledge
to Local Context
Identify Problem
Identify, Review,
Select Knowledge
Sustainability:
• Leg ulcer service still available in Ottawa region
• Protocol was expanded to 3 other regions (still in
use in 2)
• Completed RCT of home vs clinic care
• RCT completed of two compression technologies
– currently being analyzed
Lessons learned from using a
collaborative approach (IKT):
 Moving research to practice is an iterative process
of using external evidence and producing local
‘evidence’ for planning, implementing and evaluating
 Successful implementation requires
 strategic alliances between researchers & health
setting (co-production of knowledge)
 population health principles
 needs-based planning
 working at both clinical and health services levels
 a conceptual framework
More lessons learned from using a
collaborative approach (IKT):
In moving research to practice the role of the researcher
is to:
 create & facilitate a strategic alliance and a
solutions-focused collaboration for co-production
of knowledge
 bring science of synthesis to practice
 use rigorous methods for each step
(organizational planning, guideline appraisal &
adoption, evaluation of the implementation)
 use a conceptual framework to underpin the
research and KT
More lessons learned:
In moving research to practice the role of the
knowledge-users (e.g. providers and policy makers)
is to:
 Identify the problem and engage researchers in
developing the research questions
 Create and facilitate the strategic alliance and
solutions-focused collaboration for co-production
of knowledge
 Bring their practice-based knowledge and
experience to bear
 Apply the findings
KT: closing the gap between
evidence and action
How to close the gap between evidence and action:
 shift attention from individual adopters to the
organizational and environmental context for
change
 set targets for change
 monitor uptake of the research and evaluate the
health and system outcomes/impact
 keep it simple
 focus on a few important targets, practical
indicators
KT: closing the gap between
evidence and action
Remember KT 101:
 KT for what purpose? Instrumental, conceptual
knowledge use?
 Who is/are the intended audience(s)?
 What is the message? Is it clear and
unambiguous?
 What is the medium?
 To what effect?
KT: closing the gap between
evidence and action
Making a change
Making a change requires systems thinking
In theory, there is no difference between theory
and practice. But in practice, there is.
Yogi Berra
Baseball guy
For more information, visit our web page:
http://www.cihr-irsc.gc.ca/e/29418.html
http://www.cihr-irsc.gc.ca/f/29418.html
[email protected]
Thank you