CLAHRC for South Yorkshire Collaboration for Leadership in Applied Health Research and Care for...

CLAHRCfor South Yorkshire

Collaboration for Leadership in Applied Health Research and Care for South Yorkshire (CLAHRC SY). www.clahrc-sy.nihr.ac.uk

Translation of Knowledge into Better Quality Care

Learning from the NIHR CLAHRC for South Yorkshire

Kate Gerrish & Andrew Booth

[email protected]

CLAHRC for South Yorkshire

Outline

• Kate Gerrish

Overview of the CLAHRC initiative

• Kate Gerrish

Translating knowledge into action: an example

• Andrew Booth

Knowledge into action: everybody’s business!


NIHR Collaboration for Leadership in Applied Health Research and Care for South Yorkshire (CLAHRC)

NIHR programme of applied research, and implementation of research focusing on self management of long-term conditions

COPD, diabetes, obesity, stroke, genetics, chronic depression, health inequalities, telehealth

Collaboration between universities, NHS commissioners and healthcare providers

Building capacity to undertake research and implementation

£20 million over 5 years (2008-2013)£10m from NIHR with matched funding from partners

BarnsleyDoncaster

Rotherham Sheffield


Translating knowledge into action

• To achieve improvements in the quality of patient care and service delivery through developing step change in the implementation of research evidence into healthcare practice

Aim


Principles

• Priorities identified by NHS partners.• NICE guidelines, national guidance etc.

Focus on NHS clinical priorities for which there is an evidence-base

• Projects embedded within the NHS• Shared ownership• Focus on multi-disciplinary teams to change practice

Partnership working to facilitate KT

• Use KT frameworks to guide implementation• Evidence-based strategies to implement change• Embedded evaluation & feedback

Use evidence-based strategies to achieve change

• Knowledge translation facilitator secondments from NHS partners• Knowledge translation research secondments from HEI partners

Capacity building


Knowledge translation

Closing the gap between what we know and what we do

Making users (practitioners, managers, patients) aware of knowledge / innovations and facilitating their use of it to improve patient care and care delivery


KT is a dynamic, iterative process that includes the synthesis, dissemination, exchange, and ethically sound application of knowledge within a complex system of interactions among researchers and users with the intention to improve the health of (Canadians), provide more effective health services and products, and strengthen the health care system

Canadian Institutes for Health Research


Clinically focused KT projects

Management of patients

with dysphagia

Oral nutrition support for patients at

risk of malnutrition

Reducing the risk of

hospital acquired VTE


KT projects focused on service delivery

Trialling and evaluating an organisational

approach to quality improvement through the

implementation of a Microsystems

Coaching Academy

Evaluating the application of clinical

microsystems methodology to redesigning a

community falls service

Promoting patient safety through cross boundary working to promote medicines

re-ablement


KT projects focused on theory development

Tinkering and tailoring:

understanding the trajectory of

complex innovations in

healthcare setting

Exploring scale-up, spread and sustainability:

tracing a health care innovation

about dysphagia

KT casebook: capturing learning from KT initiatives



Translating knowledge into action

Implementing evidence on the prevention of hospital acquired

venous thrombo-embolism


Aims

• Patients risk assessed on admission and 24 hours later

• Patients at risk prescribed appropriate prophylaxis in accordance with NICE guidance

• Patients provided with anti-embolism stockings have them fitted and monitored in accordance with NICE guidance

• Patients/carers offered information (written & verbal) on VTE prevention as part of admission and discharge process

To reduce the risk of hospital acquired VTE by ensuring

Approach

• Medical wards in one within an English NHS Foundation Trust

Setting

• Action research approach using Knowledge to Action cycle (Graham et al 2006)

Approach

• Facilitation using best practice champion model• Education intervention• Audit and feedback, Root cause analysis

Implementation strategies

• observation, interviews, questionnaires• feedback interim data to evaluation wards

Data collection methods

MonitorKnowledge

Use

SustainKnowledge

Use

EvaluateOutcomes

AdaptKnowledge

to Local Context

Assess Barriers/Supports to

Knowledge Use

Select, Tailor,Implement

Interventions

Identify Problem

Identify, Review,Select Knowledge

Products/Tools

Synthesis

Knowledge Inquiry

Tailo

ring

Kno

wle

dge

KNOWLEDGE CREATION

ACTION CYCLEAPPLICATION

Knowledge to Action Graham et al 2006


Knowledge Inquiry

Knowledge synthesis

Knowledge tools /

products

Tailoring knowledge

Systematic reviews risk assessment & prevention of VTEExemplar sites

NICE guidanceNICE Quality StandardsRisk assessment toolsPatient information

Knowledge creation

Primary research

Identify problem

Select knowledge

Adapt knowledge to local context

Assess barriers to knowledge

use

Select, tailor implement

interventions

Monitor knowledge use

Evaluate outcomes

Sustain knowledge use Review guidelines

Develop local policy

Appraise national screening tool, patient information

Action research approach

Multi-level problem identification Understand macro, meso, micro context

Ensure ownership of need for change at different levels of the organisation

Collect baseline data observation, audit

Survey knowledge, risk assessment / prevention VTE

Feedback baseline data to ward teams

Develop interventions andtailor to local context.Facilitate implementation of interventions in collaboration with front-line staff

Modify interventions in response to changes in local context

Repeat baseline data collectionFeedback from best practice champion, clinical staff and patient representatives via Project Steering Group

Measure patient & staff outcomesEvaluate intervention / implementationstrategies

Phased withdrawal of facilitation

Ongoing audit to monitor sustainabilityRoll out of interventions and disseminate learning


• Knowledge was limited but has improved• Medication knowledge was good, then decreased when medication

changed, now improved again• Prevention was not seen as a clinical priority but this is changing

Knowledge & attitudes

• Patients received prophylaxis & still developed VTE• Estimation that 50% of people develop VTE in the community

Root cause analysis

• Initially risk assessment compliance was poor & prescribing of chemical prophylaxis was good

• Risk assessment has improved significantly to attain CQUIN / patient safety targets

• Other aspects that are improving are provision of patient information, prescribing / management of anti embolic stockings

Compliance

Outcomes


Challenges

• Board to bedside – importance of strategic and clinical leadership

Establishing effective engagement

• Immediacy of NHS agenda

Reconciling different agendas and time frames

• Lack of organisational slack in the NHS

Organisational capacity for change

• Whole systems to clinical micro-systems change

Dealing with unpredictability

Sustainability of change



Knowledge Into Action: Everybody’s Business!

Andrew Booth


Take Home Points

Information Evidence Knowledge & Know How

Not “knowledge brokers” but “knowledge broking roles”

Global “Local” Localised “Patch”

Knowledge throughout Action

New skills/knowledge build on existing strengths

The Knowledge Supply ChainInformation

Evidence

Knowledge

The Knowledge Supply Chain

Information

Evidence

Knowledge

Brokerage roles

Brokerage roles

Brokerage roles

Increasing Importance of Context


Q. Who are the Knowledge Brokers?

Strategic Brokering of Priorities and Actions (NHS/CLAHRC/University)Facilitators (CLAHRC/NHS/University)

Local leads (NHS/CLAHRC)

Local academics (University/CLAHRC)

National/International academics (Universities)

A…..We All Are!

(i.e. Knowledge Broker is a role not a job description! Main variables are type of knowledge, context and intensity of involvement)


“Our experience with the Knowledge to Action theme of the National Institute for Health Research-funded South Yorkshire Collaboration for Leadership in Applied Health Research and Care (CLAHRC) suggests that the knowledge broker position is not a single role but rather comprises a complex network of complementary roles”.

Booth A. Bridging the 'Know-do gap': a role for health information professionals? Health Info Libr J. 2011; 28(4):331-4.


What is the Knowledge?

Role KnowledgeStrategic National/Local Priorities; Local

Context; KT methods

Facilitators The Health Service; Facilitation

Local Leads “Patch” knowledge; clinical expertise

Local Academics Local context; KT methods

National/ International Academics*

Models, Techniques and Examples

* e.g. Professor Huw Davies; Professor Ian Graham


Some ExamplesRole ExampleStrategic What are the Must-Dos? Locally?

Nationally? Who do we need to influence?

Facilitators What is After Action Review? How has it been used in the NHS?

Local Leads Which wards can we work with? Who are their Opinion Leaders? Who do I need to speak to?

Local Academics What is Implementation Fidelity? Why is it Important? How do you collect, organise and share Good Practice?

National/ International Academics

How useful is the Canadian Institutes of Health Research model of knowledge translation? What are the advantages of the Knowledge to Action framework?


Achievements

Role ExampleStrategic Organisational relevance/support

Facilitators Judicious Selection of Methods. Successful Change projects. Organisational Learning.

Local Leads Local relevance/support/capacity

Local Academics Tools, Individual and Team Training & Development; Structure for KT Workbook

National/ International Academics

Organisational Training & Development; Capacity Building


150 Google Scholar Citations


Knowledge Throughout Action

Evidence Search and Synthesis (Initiation)

• e.g. patient safety in community medicine management

Identification of Good Practice (Consolidation & Review)

• e.g. After Action Review

Identification of Models/Theories (Evaluation)

• e.g. Sustainability and Spread

Identification of Good Practice (Dissemination)

• e.g. KT Workbook


Building on Existing Skills

Searching (Literature and Good Practice)

Synthesis (Scoping/Mapping etc)

Facilitation (cp. Evidence Based Practice)

Development of Tools/Checklists etc.

Dissemination Products and Mechanisms

BUT ALSO

Local Knowledge

Knowledge of the NHS


A Brief Note on Sources

Good Practice

• e.g. King’s Fund Library • e.g. SHSC Health Management Library and Information Service

Knowledge Translation

• e.g. KT Clearing House http://ktclearinghouse.ca/• e.g. Canadian Foundation for Healthcare Improvement http://www.cfhi-fcass.ca/ • e.g. Implementation Science http://www.implementationscience.com/

http://ktclearinghouse.ca/

http://www.cfhi-fcass.ca/

http://www.implementationscience.com/


Take Home Points - Recap

Information Evidence Knowledge & Know How

Not “knowledge brokers” but “knowledge brokering roles”

Global “Local” Localised “Patch”

New skills/knowledge built on existing strengths


“The value of a team approach comes not simply from the cumulation of skills, knowledge and expertise. Arguably an even more important outcome comes from the broadening of perspective offered by different disciplinary backgrounds and interests”.

Booth A. Bridging the 'Know-do gap': a role for health information professionals? Health Info Libr J. 2011; 28(4):331-4.


Conclusions

Challenges / barriers to knowledge translation

Enablers

• Techniques and tools• Leadership and collaboration• Knowledge brokering


Conclusions

• Implementation in the real world is complex and messy

• We need to be able to deal with unpredictability, be able to adapt and cope with complexity

• Knowledge brokering, leadership and collaboration, tools and techniques help handle this complexity



ContactsKate Gerrish: [email protected]

Andrew Booth: [email protected]

This presentation presents independent research by the Collaboration for Leadership in Applied Health Research and Care for South Yorkshire (NIHR

CLAHRC SY). The views and opinions expressed are those of the authors, and not necessarily those of the NHS, the NIHR or the Department of Health. CLAHRC SY

would also like to acknowledge the participation and resources of our partner organisations. Further details can be found at www.clahrc-sy.nihr.ac.uk.

mailto:[email protected]

mailto:[email protected]

http://www.clahrc-sy.nihr.ac.uk/

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