liz stirling and jacqueline tetroe
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Knowledge Translation at the Canadian Institutes of Health Research
NCDDR Web cast
December 6, 2006
Liz Stirling and Jacqueline Tetroe
Outline for the discussion
1. Knowledge Translation at CIHR• Definitions, purpose and rationale for knowledge
translation2. How widely can the concept of knowledge
translation be applied?3. But what does KT really mean?4. Knowledge to Action – Graham et al 20065. Knowledge Translation – good in theory - how can it
work in practice?6. How to measure the impact of Knowledge
Translation7. Moving knowledge to action: Best practice for
wound care 2
Outline for the discussion
1. Knowledge Translation at CIHR• Definitions, purpose and rationale for knowledge
translation2. How widely can the concept of knowledge
translation be applied?3. But what does KT really mean?4. Knowledge to Action – Graham et al 20065. Knowledge Translation – good in theory - how can it
work in practice?6. How to measure the impact of Knowledge
Translation7. Moving knowledge to action: Best practice for
wound care 3
Knowledge Translation at CIHRDefinitions, purpose and rationale for knowledge
translation
Knowledge translation is the exchange, synthesis and ethically-sound application of knowledge - within a complex system of interactions among researchers and users - to accelerate the capture of the benefits of research for Canadians through improved health, more
effective services and products, and a strengthened health care system
4
Knowledge Translation at CIHRDefinitions, purpose and rationale for knowledge
translation
Context for the CIHR definition
As described in the CIHR Act, knowledge translation is a broad concept. It encompasses all steps between the creation of new knowledge and its application to yield beneficial outcomes for society. This includes knowledge dissemination, communication, technology transfer, ethical context, knowledge management, knowledge utilization, two-way exchange between researchers and those who apply knowledge, implementation research, technology assessment, synthesis of results within a global context, development of consensus guidelines, and more.
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Knowledge Translation at CIHRDefinitions, purpose and rationale for knowledge
translation
Key point is that interactions between researchers and stakeholders may vary in intensity, complexity and level of engagement depending on the nature of the research results and on the needs of the particular stakeholder.
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Knowledge Translation at CIHRDefinitions, purpose and rationale for knowledge
translation
What is NOT KT?
For example, KT is NOT:
Continuing Medical Education
Continuing Professional Development
Translational Research
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Knowledge Translation at CIHRDefinitions, purpose and rationale for knowledge
translation
What is Continuing Medical Education?
CME generally refers to planned educational activities intended to further the education and training of specific health professionals for the enhancement of practice, education, administration and research or Professional Development
8
Knowledge Translation at CIHRDefinitions, purpose and rationale for knowledge
translation
What is Continuing Professional Development?
This includes educational methods beyond the didactic, embodies concepts of self-directed learning and personal development and considers organizational and system factors
9
Knowledge Translation at CIHRDefinitions, purpose and rationale for knowledge
translation
What is Translational Research?
Translational research is about finding solutions to clinical problems. Ideally it involves two way interactions between basic/fundamental scientists and clinicians and requires moving between scientific discoveries and clinical applications
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Knowledge Translation at CIHRDefinitions, purpose and rationale for knowledge
translation
The distinction between translational research and KT is that KT is the next step in the process - the widespread dissemination of the clinical application once it has been proven beneficial by clinical research would be considered KT (i.e. translational research ends with the development and/or testing of the clinical application and does not include its widespread promotion).
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Knowledge Translation at CIHRDefinitions, purpose and rationale for knowledge
translation
The rationale for KT:
1. Creation of new knowledge often does not, by itself, lead to its widespread adoption or impact health
2. Increased emphasis on research governance and accountability from many levels: federal and provincial government, as well as the public
12
Knowledge Translation at CIHRDefinitions, purpose and rationale for knowledge
translation
3. The mandate of CIHR includes KT: To excel, according to internationally accepted standards of
scientific excellence, in the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products and a strengthened Canadian health care system."
4. To move research into practice/action
and ultimately,
5. To improve the health of Canadians.
13
Knowledge Translation at CIHRDefinitions, purpose and rationale for knowledge
translation
Historical perspective of KT in Canadian Health funding organizations:
• The Alberta Heritage Foundation for Medical Research started to identify the need in the early 1990’s, using the term “research in practice” – and developed a model
• The Canadian Health Services Research Foundation– founded in 1996 – focused on linkage and exchange and knowledge brokering and brought these concepts into academic forums
• Change from MRC to CIHR in 2000 – KT became part of the mandate
14
Outline for the discussion
1. Knowledge Translation at CIHR• Definitions, purpose and rationale for knowledge
translation2. How widely can the concept of knowledge
translation be applied?3. But what does KT really mean?4. Knowledge to Action – Graham et al 20065. Knowledge Translation – good in theory - how can it
work in practice?6. How to measure the impact of Knowledge
Translation7. Moving knowledge to action: Best practice for
wound care 15
How widely can the concept of knowledge translation be applied?
• KT is an issue at the local, national and international level
• What distinguishes the levels is the end user/target audience
• The process is essentially the same at each level
• The impact of KT can filter up or down the levels
• In our view, we need to link globally and act locally
16
How widely can the concept of knowledge translation be applied?
• KT is not unique to medical research• The concept has been used in many other
disciplines – and is known by other names: technology transfer, knowledge management, change management etc.
• The process that is KT is appropriate to any discipline – it is about facilitating the uptake of research
• While the process is universal, the content/context does vary
17
Outline for the discussion
1. Knowledge Translation at CIHR• Definitions, purpose and rationale for knowledge
translation2. How widely can the concept of knowledge
translation be applied?3. But what does KT really mean?4. Knowledge to Action – Graham et al 20065. Knowledge Translation – good in theory - how can it
work in practice?6. How to measure the impact of Knowledge
Translation7. Moving knowledge to action: Best practice for
wound care 18
But what does KT really mean?
How does the term KT differ from the term research utilization?
• Depends on how one defines :”research” and on how one defines “knowledge”
• We think of research as a subset of knowledge• We are not getting involved in the debate over the
definition of “evidence”1
1 See, for example: Conceptualizing and combining evidence for health system guidance. http://www.chsrf.ca/other_documents/evidence_e.php
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But what does KT really mean?
Knowledge translation versus research utilization continued
• Starting in the early 1970s, research utilization was the term used to describe the incorporation of research evidence into clinical practice.
• Since then, many nursing models of research utilization have been developed.
20
But what does KT really mean?
What is meant by research utilization?• A term used predominantly by the nursing
professions
• The definition has become more precise over time• A process of using findings from conducting
research, to guide practice – Titler et al 1999• The process by which scientifically produced
knowledge is transferred to practice – Brown 1999
21
But what does KT really mean?
Definition of research utilization continued• The use of research findings in any and all aspects
of one’s work as a registered nurse – Estabrooks 1998
• Process by which specific research-based knowledge (science) is implemented in practice - Estabrooks 2003
• A specific kind of knowledge utilization whereby the knowledge has a research base to substantiate it. It is a complex process in which knowledge, in the form of research, is transformed from the findings of one or more studies into instrumental, conceptual, or persuasive utilization - Estabrooks 2006
22
But what does KT really mean?
Research utilization Evidence based practice Moving knowledge to practice Knowledge to action
The specific words used are not important per se – what is important is how these terms are operationalized
23
But what does KT really mean?
Research utilization Evidence based practice Moving knowledge to practice Knowledge to action
Ian Graham, CIHR Vice President of Knowledge Translation, uses the term “knowledge to action”2
Knowledge to action is an organic process with defined steps - it is a process
2 Graham, I.D., Logan, J., Harrison, M., Straus, S., Tetroe, J.M., Caswell, W. and Robinson, N. 2006. Lost in translation: Time for a map? Journal of Continuing Education in the Health Professions 26:13-24
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Outline for the discussion
1. Knowledge Translation at CIHR• Definitions, purpose and rationale for knowledge
translation2. How widely can the concept of knowledge
translation be applied?3. But what does KT really mean?4. Knowledge to Action – Graham et al 20065. Knowledge Translation – good in theory - how can it
work in practice?6. How to measure the impact of Knowledge
Translation7. Moving knowledge to action: Best practice for
wound care
25
Knowledge to Action CycleKnowledge to Action – Graham et al 2006
26
Knowledge to Action – Graham et al 2006
How was this model derived?
• The Knowledge Creation “funnel”• The Action Cycle
27
Knowledge to Action – Graham et al 2006
How was this model derived?
1. The Knowledge Creation “funnel”
• Importance of synthesis
• To contextualize and integrate the findings of an individual research study within a larger body of literature.
• Synthesis can take the form of a systematic review, or follow the methods developed by the Cochrane Collaboration, or use quantitative or qualitative methods or result from a consensus conference or expert panel.
28
Knowledge to Action – Graham et al 2006
How was this model derived?
1. The Knowledge Creation “funnel”• Importance of systematic reviews
• Used to create knowledge tools ie provide the data content for incorporation in practice guidelines
• Used to determine best practice (that needs to be implemented)
• To create a context for and establish an evidence base for the knowledge to be translated
29
Knowledge to Action – Graham et al 2006
How was this model derived?
1. The Knowledge Creation “funnel”• Importance of grading evidence within
systematic reviews• Establishes the credibility of the evidence
base of the knowledge to be “translated”• Creates a hierarchy of types of evidence to
guide the synthesis of knowledge
30
Knowledge to Action – Graham et al 2006
How was this model derived?
2. The Action Cycle
First – a lesson on implementation theories; • Classical: passive descriptive models-
(normative) eg. diffusion theory – used to retrospectively understand change
• Planned: action models – designed specifically to be used to bring about change
31
Knowledge to Action – Graham et al 2006
One example of a planned action theory/framework:
The Ottawa Model of Research Use (OMRU)• About moving research findings/evidence
into practice• There are other good models – this is just an
example
32
33
Knowledge to Action – Graham et al 2006
Action categories derived from the constructs of all the planned action theories we reviewed:
• Identify the problem• Identify the need for change• Identify change agents• Identify target audience• Assess barriers• Review evidence/ literature or develop
innovation
34
Knowledge to Action – Graham et al 2006
Action categories continued…
• Tailor/develop intervention• Link(age)• Implement• Evaluate
• Develop evaluation plan• Pilot test• Evaluate the process• Evaluate outcomes
• Maintain change• Disseminate
35
Knowledge to Action CycleKnowledge to Action – Graham et al 2006
36
Outline for the discussion
1. Knowledge Translation at CIHR• Definitions, purpose and rationale for knowledge
translation2. How widely can the concept of knowledge
translation be applied?3. But what does KT really mean?4. Knowledge to Action – Graham et al 20065. Knowledge Translation – good in theory - how can it
work in practice?6. How to measure the impact of Knowledge
Translation7. Moving knowledge to action: Best practice for
wound care
37
Knowledge Translation – good in theory - how can it work in practice?
Who is responsible for what in the knowledge translation process?
Depends on the particular situation• The key process to keep in mind is
linkage/communication with key stakeholders • In cases where implementation (knowledge to action)
is required, ensure agreement on:• the need for change• the evidence for change• methods and the evaluation of the impact of the
change • as well as who should do what…
38
Knowledge Translation – good in theory - how can it work in practice?
In what ways can researchers best contribute to the KT process?
They can:• contribute to the science as well as the practice of KT• conduct needs assessments• conduct systematic reviews pointing to a need for change• create an appetite for research results• keep communication lines open• conduct research with a ready audience having a perceived
need for the research results • be knowledge brokers• be systematic and rigorous
39
Knowledge Translation – good in theory - how can it work in practice?
Role of consumers in knowledge translation
• How they can contribute depends on their role – are they on the receiving end or are they the drivers of change?
• In Canada there are many examples of vocal lobby groups driving political agendas – ie pro choice, gay marriage, HIV/AIDS research
• At CIHR, for example – the Institute for Musculoskeletal Health and Arthritis (IMHA) involves consumers in a number of different ways
40
Outline for the discussion
1. Knowledge Translation at CIHR• Definitions, purpose and rationale for knowledge
translation2. How widely can the concept of knowledge
translation be applied?3. But what does KT really mean?4. Knowledge to Action – Graham et al 20065. Knowledge Translation – good in theory - how can it
work in practice?6. How to measure the impact of Knowledge
Translation7. Moving knowledge to action: Best practice for
wound care 41
How to measure the impact of Knowledge Translation
• How to measure impact is the six million dollar question – whether it is framed to be about the KT process or the impact of KT
• Depends on one’s definition and on the perspective of the stakeholder
• Can develop measures of each step of the K to A process, but there is no empirical data to suggest how to weight the various components• Can assess degree of activity or linkage or use of
knowledge at each of the steps
42
How to measure the impact of Knowledge Translation
Need to consider types of impact:• instrumental (applying research results in specific,
direct ways),
• conceptual (using research results for general enlightenment, results influence actions but more indirectly and less specifically than in instrumental use)
or • symbolic (using research results to legitimate and
sustain predetermined positions)3
3 Beyer, J.M. 1997. Research utilization: Bridging the gap between communities. Journal of Management Inquiry 6 (1): 17-22.
43
How to measure the impact of Knowledge Translation
• Canadian Health Services Research Foundation (CHSRF), and the Alberta Heritage Foundation for Medical Research (AHFMR) have been making some progress on the question of assessing impact, as has CIHR
• CIHR has developed a framework for evaluation of the impact of the research we fund4
4 Developing a CIHR Framework to Measure the Impact of Health Research
http://www.cihr-irsc.gc.ca/e/153.html
44
How to measure the impact of Knowledge Translation
Stakeholders Perspectives
Higher educationSector
Health professionals & Administrators
Society
Academic ExcellenceKnowledge productionCapacity building
Effective treatments and diagnosticsEffectiveness and efficiency of the health care system
•Response to public health threats•Improved health care •Improved health status•Efficiency and sustainability
45
How to measure the impact of Knowledge Translation
Stakeholders Perspectives
Industry
Government
Commercial potential
Public health and responses to health threats
Health status
Contribution to economic growth and productivity
Efficiency and sustainability of health systems
46
How to measure the impact of Knowledge Translation
Examples of sources of data for measuring impact of knowledge translation
• Citation impact analyses (e.g. bibliometric studies)
• End-of-Grant reports• Case studies• Interviews/surveys• Administrative data bases• Document analysis
47
Outline for the discussion
1. Knowledge Translation at CIHR• Definitions, purpose and rationale for knowledge
translation2. How widely can the concept of knowledge
translation be applied?3. But what does KT really mean?4. Knowledge to Action – Graham et al 20065. Knowledge Translation – good in theory - how can it
work in practice?6. How to measure the impact of Knowledge
Translation7. Moving knowledge to action: Best practice for
wound care
48
Moving knowledge to action: Best practice for wound care
• 7 year program of research and implementation• Led by Ian Graham and Margaret Harrison5
• Community care of venous leg ulcers• Collaborative interdisciplinary approach• Excellent means of illustrating the knowledge to
action cycle
5A community-researcher alliance to improve chronic wound careCIHR KT Casebook, (Graham et al, 2006)http://www.cihr-irsc.gc.ca/e/30669.html
49
Knowledge inquiry
Knowledge synthesis
Knowledge tools/
products
Tailo
ring
kno
wle
dge
Knowledge Creation
Identify Problem
Identify, Review Select
knowledge
Adapt knowledgeto localcontext
Assess barriers
to knowledge use
Select, tailorimplement
interventions
Monitorknowledge
use
Evaluateoutcomes
Sustainknowledge
use
50
Moving knowledge to action: Best practice for wound care
Leg Ulcers are:• Common, costly, complex• Chronic, recurring• Debilitating, isolating condition• 80% care reported to be community-based,
delivered by nurses
51
Moving knowledge to action: Best practice for wound care
Background work to understand the local:• Population• Providers, scopes of practice• Practice environment• Gaps re: evidence-based practice
Then, formed an alliance between decision-makers, clinicians (and researchers) for planning, and to design and conduct a needs assessment
52
Moving knowledge to action: Best practice for wound care
• High level evidence for assessment and management of venous ulcers
• Numerous international Clinical Practice Guidelines available
53
Knowledge inquiry
Knowledge synthesis
Knowledge tools/
products
Tailo
ring
kno
wle
dge
Knowledge Creation
Identify Problem
Identify, Review Select knowledge
Adapt knowledge
to localcontext
Assess barriers
to knowledge use
Select, tailorimplement
interventions
Monitorknowledge
use
Evaluateoutcomes
Sustainknowledge
use
54
Moving knowledge to action: Best practice for wound care
1. Identify a Clinical Area to Promote Best Practice
2. Establish an Interdisciplinary Guideline
Evaluation Group
3. Establish Guideline Appraisal Process
4. Search and Retrieve Guidelines
5. Guidelines Assessmenta) Qualityb) Currencyc) Content
6. Adaptation of Guidelines for Local Use
7. External Review – Practioner and Policy Maker Feedback;
Expert Peer Review
8. Finalize Local Guideline
9. Official Endorsement and Adoption of Local
Guideline
10. Scheduled Review and Revision of Local Guideline
1. Identify a Clinical Area to Promote Best Practice
2. Establish an Interdisciplinary Guideline
Evaluation Group
3. Establish Guideline Appraisal Process
4. Search and Retrieve Guidelines
5. Guidelines Assessmenta) Qualityb) Currencyc) Content
6. Adaptation of Guidelines for Local Use
7. External Review – Practioner and Policy Maker Feedback;
Expert Peer Review
8. Finalize Local Guideline
9. Official Endorsement and Adoption of Local
Guideline
10. Scheduled Review and Revision of Local Guideline
Practice Guidelines Evaluation and Adaptation Cycle (Graham et al 1999; Graham et al 2005)
55
Knowledge inquiry
Knowledge synthesis
Knowledge tools/
products
Tailo
ring
kno
wle
dge
Knowledge Creation
Identify Problem
Identify, Review Select knowledge
Adapt knowledgeto localcontext
Assess barriers
to knowledge
use
Select, tailorimplement
interventions
Monitorknowledge
use
Evaluateoutcomes
Sustainknowledge
use
56
Moving knowledge to action: Best practice for wound care
From the Ottawa Model of Research Use (OMRU) we know to assess barriers at the level of:
• The guideline
• The potential adopters
• The practice environment
57
Moving knowledge to action: Best practice for wound care
Approach to barriers assessment included:
• Knowledge, attitudes and practice (KAP) surveys of nurses and physicians (Graham, Harrison, Friedberg et al. 2001; Graham, Harrison, Shafey et al. 2003)
• Practitioner/policy maker feedback on adapted care protocol
• Discussions with providers and managers
58
Knowledge inquiry
Knowledge synthesis
Knowledge tools/
products
Tailo
ring
kno
wle
dge
Knowledge Creation
Identify Problem
Identify, Review Select knowledge
Adapt knowledgeto localcontext
Assess barriers
to knowledge use
Select, tailorimplement
interventions
Monitorknowledge
use
Evaluateoutcomes
Sustainknowledge
use
59
Moving knowledge to action: Best practice for wound care
Interventions for implementation
1. Provider level
Training for nurses (UK N18 course, doppler & bandaging training)
2. 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
60
Knowledge inquiry
Knowledge synthesis
Knowledge tools/
products
Tailo
ring
kno
wle
dge
Knowledge Creation
Identify Problem
Identify, Review Select knowledge
Adapt knowledgeto localcontext
Assess barriers
to knowledge use
Select, tailorimplement
interventions
Monitorknowledge
use
Evaluateoutcomes
Sustainknowledge
use
61
Recommendations Uptake
Parameters of EBCPG
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)
Moving knowledge to action: Best practice for wound care
62
Knowledge inquiry
Knowledge synthesis
Knowledge tools/
products
Tailo
ring
kno
wle
dge
Knowledge Creation
Identify Problem
Identify, Review Select knowledge
Adapt knowledgeto localcontext
Assess barriers
to knowledge use
Select, tailorimplement
interventions
Monitorknowledge
use
Evaluateoutcomes
Sustainknowledge
use
63
Moving knowledge to action: Best practice for wound care
Evaluation of outcomes
64
Moving knowledge to action: Best practice for wound care
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
65
Knowledge inquiry
Knowledge synthesis
Knowledge tools/
products
Tailo
ring
kno
wle
dge
Knowledge Creation
Identify Problem
Identify, Review Select knowledge
Adapt knowledgeto localcontext
Assess barriers
to knowledge use
Select, tailorimplement
interventions
Monitorknowledge
use
Evaluateoutcomes
Sustainknowledge
use
66
Moving knowledge to action: Best practice for wound care
Sustainability still under investigation:
• Protocol expanded to 3 other regions
• RCT underway of home vs clinic care
• RCT underway of two compression technologies
67
Moving knowledge to action: Best practice for wound care
Lessons learned: • Moving knowledge to action is an iterative process of using external evidence and producing local ‘evidence’ for planning• Successful implementation requires
• Strategic alliances between researchers & health setting
• Population health principles• Needs-based planning • Working at both clinical and health services
levels
68
Moving knowledge to action: Best practice for wound care
Lessons learned continued:
In moving research to action the role of the researcher is to:create & facilitate a strategic alliance and a problem-focused collaboration bring “science of synthesis” to practiceuse rigorous methods for each step (organizational planning, guideline appraisal & adoption, evaluation of the implementation)use conceptual frameworks to underpin the research
69
In conclusion
Knowledge Translation is:• Collaborative• Iterative• Complex• Time consuming• Never really completed
It requires:• Persistence• Patience• Expertise with multiple research methods • Problem solving skills• People skills
70
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