KT Master Class CLAHRC Conference Sheffield, UK October 5 th , 2010

1. Illustration of the Knowledge to Action ProcessIan D Graham PhDCIHRVice President, Knowledge Translationand Public Outreach KT Master Class CLAHRC Conference Sheffield, UK October 5th, 2010

2. 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

3. Knowledge, if it does not determine action, is dead to us. Plotinus (Roman philosopher 205AD-270AD)

4. Emergency instructions for those who are theory averse

5. 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 from: Graham et al: Lost in Knowledge Translation: Time for a Map? http://www.jcehp.com/vol26/2601graham2006.pdf

6. 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

7. 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.iceberg-grebeci.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.

9. 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

10. 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

11. 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)

12. 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.

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14. 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.

15. 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.

16. 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

17. 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

18. A Picture is Worth a 1,000 Words

19. 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

20. 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

21. Knowledge Inquiry Tailoring Knowledge 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

22. 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)

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

24. 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

25. 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)

26. 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

28. 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/supports 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)

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/supports 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 • Positive attitudes toward care of individuals with leg ulcers • Nurses better knowledge of than others

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 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

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 • Developed tools to facilitate use of the recommendations • Protocol algorithm (knowledge tool/adaptation/intervention) • Assessment and documentation tools

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 Monitor Knowledge Use

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 Evaluate Outcomes

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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?

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

42. Making a change requires systems thinking

43. In theory, there is no difference between theory and practice. But in practice, there is. Yogi Berra Baseball guy

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