Lost in Translation: Navigating Knowledge Translation Landscape

1. Lost in Translation:How I found the wayIan D Graham PhDCIHRVice President, Knowledge Translationand Public Outreach KT Canada Seminar Series April 8th 2010

2. Learning Objectives • To understand what is meant by the term integrated knowledge translation • 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

3. What is Knowledge Translation? KT 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. This process takes place within a complex system of interactions between researchers and knowledge users which may vary in intensity, complexity and level of engagement depending on the nature of the research and the findings as well as the needs of the particular knowledge user.

4. Knowledge Translation is part of our mandate

5. What is Knowledge Translation? Ethically sound application of knowledge • The contextualization and integration of research findings of individual research studies within the larger body of knowledge on the topic. • Synthesis is a family of methodologies for determining what is known in a given area or field and what the knowledge gaps are. Knowledge synthesis • Involves identifying the appropriate audience for the research findings, and tailoring the message and medium to the audience. Dissemination • Refers to the interaction between the knowledge user and the researcher resulting in mutual learning, it encompasses the concept of collaborative or participatory, action oriented research where researchers and knowledge users work together as partners to conduct research to solve knowledge users’ problems (Integrated KT). Knowledge exchange • The iterative process by which knowledge is actually considered, put into practice or used to improve health and the health system. • KT activities must be consistent with ethical principles and norms, social values as well as legal and other regulatory frameworks

6. What is Knowledge Translation? Knowledge translation is about: • Making users aware of knowledge and facilitating their use of it 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

7. At CIHR we consider two broad categories of KT The researcher develops and implements a plan for making knowledge users aware of the knowledge generated through a research project End of grant KT The researcher engages potential knowledge users as partners in the research process. Requires a collaborative or participatory approach to research that is action oriented and is solutions and impact focused. Integrated KT

8. What is integrated KT? • a way of doing research • collaborative, participatory, action-oriented, community based research, co-production of knowledge, mode 2 research • involves engaging and integrating knowledge users into the research process • Knowledge users can be: • Policy- and decision-makers from the community to the federal level, researchers, the public, industry, clinicians, the media • Investigators from different disciplines, teams, countries

9. What is integrated KT? Knowledge users and researchers (knowledge creators) work together to: • shape the research questions • interpret the study findings and craft messaging around them • move the research results into practice In our view – this is the minimum requirement for conducting integrated KT

10. What is integrated KT? In addition, knowledge users and researchers (knowledge creators) can work together to: • shape the research questions • decide on the methodology • help with data collection and tools development • interpret the study findings and craft messaging around them • move the research results into practice • widespread dissemination and application

11. iKT • Community based rather than community placed research • We understand that both can be conducted under the rubric of an iKT grant • Embarking on a study of iKT partnerships to get a sense of what “partnerships” mean to different types of researchers and different types of knowledge users

12. What is integrated KT? • We have an educational module on participatory research (Ann Macaulay, McGill http://pram.mcgill.ca/) • Available on the CIHR website: http://www.cihr-irsc.gc.ca/e/39128.html#Guide • Includes advice/discussion about how to manage research of this sort: negotiating roles and responsibilities ahead of time, dealing with IP, dealing with disagreements; guidance as to how to be mutually respectful, etc

14. Why integrated KT? Through partnerships, the research is strengthened: • research can be more solutions-based because there is an end-user involved in developing the research question • research can have more impact because the end-user is engaged and interested, ready for results and willing to move those results into practice because they are of direct relevance to their day-to-day lives

15. Learning Objectives • To understand what is meant by the term integrated knowledge translation • 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

16. Knowledge Inquiry Tailoring Knowledge Synthesis Products/ Tools Monitor Knowledge Use Select, Tailor, Implement Interventions from: Graham et al: Lost in Knowledge Translation: Time for a Map? Evaluate Outcomes KNOWLEDGE CREATION Assess Barriers/ Supports to Knowledge Use Sustain Knowledge Use Adapt Knowledge to Local Context http://www.jcehp.com/vol26/2601graham2006.pdf Identify Problem Identify, Review, Select Knowledge

17. 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 • 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

18. 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

19. A Picture is Worth a 1,000 Words

20. Knowledge Inquiry Tailoring Knowledge Synthesis Products/ Tools Monitor Knowledge Use Select, Tailor, Implement Interventions Evaluate Outcomes KNOWLEDGE CREATION Assess Barriers/ Supports to Knowledge Use Sustain Knowledge Use Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge

21. Monitor Knowledge Use Identify Problem Identify, Review, Select Knowledge Identify Problem Identify, Review, Select Knowledge Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate Outcomes Knowledge Inquiry Tailoring Knowledge Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context • 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

22. Knowledge Inquiry Tailoring Knowledge Knowledge Inquiry Synthesis Products/ Tools • Identifying the Problem • Background work to understand the local: • Population • Providers, scopes of practice • Practice environment • Gaps re: evidence-based practice

23. 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)

24. Knowledge Inquiry Tailoring Knowledge Synthesis Synthesis Products/ Tools • Identifying the problem • Systematic review of incidence/prevalence studies

25. Monitor Knowledge Use Identify Problem Identify, Review, Select Knowledge Identify Problem Identify, Review, Select Knowledge Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate Outcomes Knowledge Inquiry Tailoring Knowledge Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context • High level evidence for assessment and management of venous ulcers available (numerous RCTs, Cochrane Systematic Review) • Numerous international Clinical Practice Guidelines available

26. Monitor Knowledge Use Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate outcomes Knowledge Inquiry Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Adapt Knowledge to Local Context Practice Guidelines Evaluation and Adaptation Cycle (Graham et al 1999; Graham et al 2005)

27. 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 Integrated into the international ADAPTE process • www.adapte.org

29. Monitor Knowledge Use Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate outcomes Knowledge Inquiry Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Assess Barriers to Knowledge Use • 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)

30. Monitor Knowledge Use Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate outcomes Knowledge Inquiry Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Assess Barriers to Knowledge Use • 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

31. Monitor Knowledge Use Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate outcomes Knowledge Inquiry Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Select, Tailor, Implement Interventions • 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

32. Monitor Knowledge Use Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate outcomes Knowledge Inquiry Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Select, Tailor, Implement Interventions • Developed tools to facilitate use of the recommendations • Protocol algorithm • Assessment and documentation tools

33. Monitor Knowledge Use Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate outcomes Knowledge Inquiry Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Monitor Knowledge Use

34. Monitor Knowledge Use Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate Outcomes Knowledge Inquiry Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Evaluate Outcomes

35. 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

36. Monitor Knowledge Use KNOWLEDGE CREATION Knowledge Inquiry Synthesis Products/ Tools Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Sustain Knowledge Use Select, Tailor, Implement Interventions Evaluate Outcomes Assess Barriers to Knowledge Use Sustain Knowledge Use Adapt Knowledge to Local Context • 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

37. 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

38. 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 • 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

39. 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 • Bring their practice-based knowledge and experience to bear • Apply the findings

40. 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 evaluatethe health and system outcomes/impact • keep it simple • focus on a few important targets, practical indicators

41. 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?

42. KT: closing the gap between evidence and action Making a change

43. Making a change requires systems thinking

44. 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 ian.graham@cihr-irsc.gc.ca Thank you