Knowledge Translation: Tools for Success

1. Knowledge Translation
Moving from Best Evidence
to Best Practice
Dr. Imad Salah Ahmed Hassan MD FACP FRCPI MSc MBBS
Consultant Physician & Pulmonologist
Chairman, Knowledge Translation Committee
Department of Medicine
KAMC
Riyadh
Kingdom of Saudi Arabia
imadsahassan@gmail.com

2. Quality Chasm
• 439 indicators of clinical quality of care
• 30 acute and chronic conditions, plus prevention
• Medical records for 6712 patients
• Participants had received 54.9% of scientifically
indicated care (Acute: 53.5%; Chronic: 56.1%;
Preventive: 54.9%)
Conclusion: The “Defect Rate” in the technical
quality of American health care is approximately
45%!!!!!!!
McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-264 .

3. “Crossing the Quality Chasm”
Institute Of Medicine 2001
• Under use – helpful services not delivered
• Overuse – useless interventions
• Mistakes – inevitable human error
Crossing the Quality Chasm: A New Health System for the 21st Century, available at:
http://www.nap.edu/books/0309072808/html/

5. Other “Failure Modes in KT






Folic acid supplements pre-pregnancy
Promoting and supporting breast feeding
Promoting use of preventers in chronic
asthma
Achieving blood pressure control
Optimizing care for stroke patients
Preventing osteoporosis related fractures
reoccuring

6. Steps
What is
KT?
How to
Practice
KT?
Where Do
I Go From
Here?

7. Objectives

To define & understand knowledge
translation

To appreciate why KT is important

To provide a framework for knowledge
translation

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

9. What is Knowledge Translation?
Knowledge Translation is about:
 Making users aware of knowledge and facilitating
its use to improve health and health care systems
 Closing the gap between what we know and what
we do (reducing the know-do gap)
 Moving knowledge into action
Knowledge Translation research (KT Science) is
about:
 Studying the determinants of knowledge use and
effective methods of promoting the uptake of
knowledge

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

11. Current State of Knowledge
Translation

“health care systems globally have failed to
timely, consistently and comprehensively
apply new knowledge at both the macro and
micro levels of care”
1,2,3.4




McGlynn E, Asch S, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the
United States. N Engl J Med 2003;348:2635-45.
Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care 2001; 39:II46II54.
Shah BR, Mamdani M, Jaakkimainen L, Hux JE. Risk modification for diabetic patients. Are other risk factors treated as diligently
as glycemia? Can J Clin Pharmacol 2004;11(2):e239-e244.
Kennedy J, Quan H, Ghali WA, Feasby TE. Variations in rates of appropriate and inappropriate carotid endarterectomy for stroke
prevention in 4 Canadian provinces. CMAJ 2004; 171(5):455-459.

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

13. Current State of Knowledge
Translation
 “Bridging
this so called Knowledge-to-Action
gap has been extremely slow sometimes
taking years following the availability of new
knowledge”


Paul Glasziou and Brian Haynes. The paths from research to improved health Outcomes. Evidence-Based
Medicine 2005; 10:4-7.
Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 6570

14. Basic Concepts in KT
 Concept

No.: 1
“a set or series of interconnected or
interdependent parts or entities that act
together in a common purpose or produce
results impossible by action of one alone”.

15. Health Care Model: Donabedian
Model
Anatomy
Care
Process
Structure
Process
•Staff
•Departments
•Equipment
•Supplies
•Environment
Outcome
•Pathways
•Protocols
•Physician
orders
•Nursing Care
•Housekeeping
•Transport
Six Ds:
Death
Disease
Disability
Discomfort
Dissatisfaction
Destitution
(cost)

16. Basic Concepts in KT
 Concept



No.: 2
Organizational Structure
Professional (Knowledge, Skill or Attitude
barriers)
Social

17. Barriers to KT: Need to be
Addressed at the Outset
Organisational Barriers
Professional
Social
 Non-committed
leadership
 Lack of EBM knowledge
and skills
 Lack of time
 Lack of or no access to
information sources
 Not applicable to
individual patient
 Pharmaceutical industry
have influence on
evidence
 Organizational Chaos
 Experience not taken
into account
 Patient preferences must
be respected
 Lack of Mechanisms to
Monitor care Delivery
 Erosion of autonomy
 No financial profits

18. Basic Concepts in KT
Concept
No.: 3

19. Knowledge
Attitude
Skills
"Fit for purpose“
"Right first time"
The Close Inter-relationship and Dynamics between Staff-Competency, Quality
of Care and Knowledge Translation: Competency drives Quality which in turn
leads to better Knowledge Translation

20. The SIX Domains of Quality Care

21. The Five Essential Components for
Successful KT in Healthcare Systems


KT is primarily a concept for bringing up
change.
This change should be:



Evidence-based
be successfully Implemented using the right tools
employing established Process Change Skills
and strategies.

22. The First Three Prerequisites
Scientifically proven knowledge, based on the science
of Evidence-based Medicine
Scientifically proven successful Implementation of
Change Tools
Scientifically proven Process Change Actions

23. The Five Essential Components for
Successful KT in Healthcare Systems

KT is primarily a concept for bringing up
change.
As per the Institute for Healthcare
Improvement, any effort to improve the quality
of patient care must incorporate another new
concept namely System Redesign
The fourth essential components for a KT undertaking is
System Redesign.

24. What is System Redesign?



System redesign is a new concept in
healthcare reform.
It entails specific redesign in care delivery
both in its structure and in its process in
order to re-align a faulty system and improve
outcomes.
The whole structure or process of care is
redesigned to an “ideal process” based on
evidence.

25. The Five Essential Components for
Successful KT in Healthcare Systems



KT is primarily a concept for bringing up
change.
The fifth vital component pertains to the new
knowledge and skills that healthcare staff
have to attain to fulfill the above 4 elements.
These new competencies entail a redesign
of staff training curricula with emphasis on KT
competency as a new and extremely
essential skill.

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

27. The Five-Component Model for a Successful
Knowledge Translation Endeavour
EBM
Implementation
of Change Tools
KT
System
Redesign
Process
Change Skills
KT
Competency
Training

29. Evidence-based Practice
Ask clinical
Acquire the
questions
best evidence
Assess
5A’s !!
Appraise
effectiveness,
efficiency of EBM
process
the evidence
Apply
evidence to
Your patient

30. Acquire the Best Evidence
The Sources of Evidence Pyramid
Pre-appraised, systematic reviews:
Cochrane, DARE, Clinical Evidence, EPC
Evidence Reports (in AHRQ)
Pre-appraised, individual
studies: InfoPOEMs, ACP
Journal Club
Databases with EBM, background, and
guideline info.: InfoRetriever®, DynaMed®,
ACP’s PIER, Guideline Clearinghouse and
USPSTF (in AHRQ), NICE
Highly referenced, current e-textbook: Upto-Date, Scientific American
Standard e-textbooks,
PDA e-textbook (5MCC)
PubMed (Clinical Queries), Medline
*Adapted from Shaughnessy and Slawson

31. If you do not know where you
want to go………


Implementation/KT websites
Quality Improvement website
AHRQ Agency for Healthcare Research and Quality http://www.ahrq.gov/
NICE National Institute for Health and Clinical Excellence: www.nice.org.uk
Clinical Improvement Skills: http://www.improvementskills.org/index.cfm
Institute for Healthcare Improvement: http://www.ihi.org/IHI/Topics/LeadingSystemImprovement/
Knowledge Translation Clearinghouse: http://ktclearinghouse.ca/
ICSI Institute for Clinical Systems Improvements http://www.icsi.org/index.aspx
Health Care Improvement Skills Centre: http://improvementskills.org/
 Society of Hospital Medicine: http://www.hospitalmedicine.org/

32. It is vitally important to note that both individual and organizational factors
need to be addressed for successful implementation to take place.

33. Hierarchy of Evidence-Based
Implementation Tools
The Implementation
Pyramid
Interventions
of variable
effectiveness
•Audit and
feedback
•Use of local
opinion leaders
•Local consensus
processes
(ownership)
•Patient mediated
interventions
Consistently effective
interventions
•Educational outreach visits
•Reminders (manual or
computerized)
•Multifaceted interventions*
•Interactive educational
meetings (workshops)
•Financial Incentives
Interventions that have little or no
effect
•Educational materials (Printed practice guidelines,
audiovisual materials, and electronic publications)
•Didactic educational meetings (such as lectures)
* (a combination that includes two or more of the following: audit and feedback, reminders, local consensus
processes, or marketing)

34. Barriers for Knowledge Translation
Organisational Barriers
Professional
Social

Non-committed
leadership
 Lack of EBM
knowledge and skills
 Lack of time

Lack of or no access
to information
sources
 Not applicable to
individual patient
 Pharmaceutical
industry have
influence on
evidence

Organizational
Chaos
 Experience not
taken into account
 Patient preferences
must be respected

Lack of Mechanisms
to Monitor care
Delivery
 Erosion of autonomy
 No financial profits
 Evidence hard to
implement
 Lack of skills in
knowledge
management

35. Organisational Interventions: STRUCTURES
Unyielding leadership/regulatory body’s
support both materially and in manpower.
Specialized/KT Clinical Teams & Divisions
Multidisciplinary teams: Stroke Team, Diabetes
team, Heart Failure Team etc
Revision of professional roles e.g. increased clinical
roles to nurses and expanding the roles of
pharmacists
Compulsory KT/EBM rotation/certification/
CME hours during training.

36. Organisational Interventions
Access to medical information: Telephone
Hotline, Intranet and Internet access , Well-stocked
Medical Library , Personal Digital Assistant/Pocket
PCs etc.
Educational materials: Memos, letters, electronic
reminders (emails, discussion groups, internet
sites/links)
Education /Postgraduate Training Department.
Quality Improvement Committees
incorporating KT principles
Clinical Audit /Audit Department, Mortality
and Morbidity Review.
Regular assessment/feedback from endusers and health consumers e.g.
questionnaires, self-report activities etc.

37. Organisational Interventions
Patient-and Patient-Group mediated
Interventions*
“Patient Values & Preferences”
Patient Education Department.
Methods of Educating Patients/SelfManagement
Verbal (by doctor, nurse or trained educationalist).
Written (leaflets, booklets, posters).
Audio tapes.
Video tapes (for loan, or playing in waiting rooms etc.)
Public lectures.
Support group meetings.
Newspaper/magazine articles/Internet.
Drama.

38. Professional Interventions: PROCESS
Knowledge
Attitude
Skills

39. Professional Interventions
Knowledge
• Educational
• Workshops on KT: EBM, Process
Change, System Redesign,
Competency, Implementation Tools.
• Lectures by senior figures, leaders,
experts on improvement topics etc.

40. Professional Interventions
Attitude
• Involving important and committed individuals from all relevant
disciplines.
• Involving and informing all parties (Stakeholders).
• Implementation tool must be built into daily patients’ care.
• Implementation should take place at the point of time with clinical decisionsupport tools and real time disease and patient specific reminders.
• Linking interventions to needs.
• Needs Survey
• Incentives
•
•
•
•
•
•
•
Reduction in clinician’s workload.
Financial.
Conference/Travel reimbursements.
Recognition/Accreditation Certificates.
Endorsement by International Bodies.
Divisional/Institutional League Tables.
Protection against Litigation.

41. Professional Interventions
Skills
• Decision Support Tools: computerized reminders,
reminders incorporated in clinicians’ daily work e.g. in
Clinical Pathways and Protocols, Order Sets, Check-lists etc.
• Clinical KT Enhancing Tools:
• Morning Meeting
• Ward Round
• Journal Club
• M&M Reviews Presentations
• Audit Presentations
• Competency Training
• KT Research

43. Model for Improvement

44. Topic
Review/
Update
Team
Monitor
Objectives
Process Change
Skills
Implement
Awareness
EBM
Brainstorming
Pilot
Produce
b

45. Knowledge Application
Knowledge application (action cycle) includes:
1.
2.
3.
4.
5.
6.
7.
Identifying the problem
Adapting knowledge to local context
Assessing barriers and facilitators to knowledge use
Selecting and implementing interventions
Monitoring knowledge use
Evaluating outcomes; and
Sustaining knowledge use.

46. KT of a Classic PT Case: Can it
be Done?

Documentation o f Red Flags in referrals to PT
with Low Back Pain

Red flags are warning signs that suggest that
physician referral may be warranted.

47. LBP Red Flags












Thoracic pain
Widespread neurological deficit
Lower limb weakness
Drug abuse/human
immunodeficiency virus
Age <20 or >55 years
Weight loss
Persistent severe restriction of
lumbar flexion
Constant progressive, nonmechanical pain
Night pain
Positive cough/sneeze
Previous history of cancer
Recent history of trauma
Cauda equina symptoms




Altered bladder control
Saddle anesthesia
Altered bowel control
Widespread neurological
deficit

48. Documentation of RED Flags in
LBP Referrals to PT: POOR KT!
 USA




Saddle Anesthesia
Night Pain
LL Neurodeficits
Bladder Dysfunction
19% of Cases
68%
19%
13.8%
 UK



Scotland
33%
Leerar PJ, BoissonnauttW, Domholdt E, Roddey T. Documentation of red flags by physical therapists for patients with low back pain. J
Man Manipul Ther 2007;15:42–9.
Ferguson F, Holdsworth L, Rafferty D. Physiotherapy. Low back pain and physiotherapy use of red flags: the evidence from Scotland.
2010 ;96(4):282-8.

49. Physical Therapists’ Use of Interventions With High
Evidence of Effectiveness in the Management of a
Hypothetical Typical Patient With Acute Low Back Pain
Results.
 Use of interventions with strong
or moderate evidence of effectiveness:
68%.
 Use interventions for which research evidence
was limited or absent.
90%

50. Physical Therapists’ Use of Interventions With High
Evidence of Effectiveness in the Management of a
Hypothetical Typical Patient With Acute Low Back Pain
Discussion and Conclusion.
 Although most (not really!) therapists use
interventions with high evidence of
effectiveness, much of their patient time is
spent on interventions that
are not well reported in the literature.

Christine Mikhail et al. Physical Therapy . Volume 85 . Number 11 . November 2005

51. KT for LBP: Actions
Process Change
EBM
Implementation
Tools
System
Redesign
Competency
Training
• Skills for Management of
Change
• Education & Training
• Education, Back Pain
Clinical Pathway, Checklists
• LBP Team, LBP Monitor,
Electronic H&P, Order Set
• EBM, Implementation Tools Development,
Process Change, System redesign etc

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