continuing education, guideline implementation, and the emerging transdisciplinary field of...

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The Journal of Continuing Education in the Health Professions, Vol. 26 No. 1, Winter 2006Published online in Wiley InterScience (www.interscience.wiley.com) • DOI: 10.1002/chp.46

The Journal of Continuing Education in the Health Professions, Volume 26, pp. 5–12. Printed in the U.S.A. Copyright (c) 2006 The Alliancefor Continuing Medical Education, the Society for Medical Education, the Society for Academic Continuing Medical Education, and theCouncil on CME, Association for Hospital Medical Education. All rights reserved.

Innovations

Continuing Education, Guideline Implementation, and theEmerging Transdisciplinary Field of Knowledge Translation

Dave Davis, MD, CCFP, FCFP, FRCPC(Hon)

Abstract

This article discusses continuing education and the implementation of clinical practiceguidelines or best evidence, quality improvement, and patient safety. Continuing educationfocuses on the perspective of the adult learner and is guided by well-established educationalprinciples. In contrast, guideline implementation and related concepts borrow from the fieldsof quality improvement and patient safety and from health services research. Relative to thequestion of improved clinical outcomes, both to some extent afford only partial understand-ing of a complex issue. Knowledge translation (KT) is a transformative concept that links thebest elements of both broad fields and, in particular, adds educational elements to the workof health services researchers and others. Interdisciplinary in the extreme, KT is explored insome detail: its major elements (information, facilitation, context, the clinician-learner,among others) considered as variables in an equation leading to knowledge uptake andimproved health care outcomes and an improved functioning health care system.

Key Words: Education, continuing, medical, knowledge translation, guideline implementa-tion, quality improvement

What’s the Fuss?

A discussion regarding the terms knowledgetranslation, guideline implementation, and con-tinuing education may at first seem pedantic.There are several reasons why this may not bethe case. First, despite the sizable body of schol-arship in the delivery of adult education1,2 andresearch in planning continuing medical educa-tion (CME),3,4 substantive research in the areaof practitioner change indicates the involvement

Dr. Davis: Principal Investigator, The Knowledge TranslationProgram of the University of Toronto and St. Michael’sHospital; Professor, Health Policy, Management andEvaluation and Family and Community Medicine ContinuingEducation, University of Toronto; and Chair, GuidelinesAdvisory Committee, Ontario Medical Association/Ministryof Health and Long-Term Care, Ontario.

Correspondence: Dave Davis, MD, Faculty of Medicine,University of Toronto, 500 University Avenue, Suite 650,Toronto, Ontario, M5G 1V7

of a wide variety of forces and learningresources well beyond the traditional course orconference.5 Second, increasing emphasis onthe outcomes of continuing education (CE) haveled to discussions and understandings of evalua-tion, exceeding the traditional happiness indexand competency tests.6 Third, and most impor-tant, clinical evidence that is generated atincreasingly rapid rates is not readily availableto clinicians.7 Too often, when it is available, itis infrequently or incorrectly applied in prac-tice.8–10 This failure to rapidly adopt evidenceleaves significant gaps between high-qualityevidence and practice; significant practice vari-ation affecting quality of life11,12; increasinghealth care costs; and, of greatest importance,increasing morbidity and mortality.13–17 It is this“clinical care gap”—and the assumption thatunderstandings of continuing education, guide-line implementation, and knowledge translationmight assist in the closing of that gap—thatdrives the present discussion.

Davis

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The Journal of Continuing Education in the Health Professions, Vol. 26 No. 1, Winter 2006 • DOI: 10.1002/chp.

Case Scenario

Noting the evidence that pain in children is inad-equately controlled in the pediatric hospital set-ting, Dr. O’Brien has undertaken a yearlongprogram implementing pain guidelines withphysicians, nurses, and parents. Patterned afterthe Australian National Institute for ClinicalStudies initiatives (http://www.nicsl.com.au),these efforts include the following:

• A survey to detect pain managementproblems in the hospital (that includesmedical record audit and individual ques-tionnaires)

• The identification and enlisting of keyinfluential people in each of the hospitalwards and departments

• A hospital-wide educational campaigncalled “no pain for our kids,” involvingparents, staff, and others

• Grand rounds in each hospital area inwhich pain is an issue

• Hospital-wide nursing in-service education• Ward-based, readily available reminders

about the issue, about commonly used painmedications and weight-based dosages

• Key messages reformulated for patientwaiting rooms and wards

• The institution of a local policy mandatingnurses to ask patients and family membersabout their children’s pain14

CME Versus Guideline Implementation

A useful way to understand the gap between bestavailable evidence and clinical practice and themeans to close it is to appraise the situation por-trayed in the above scenario: which of this sce-nario’s methods are “CME” and which might becalled guideline implementation strategies?Readers of The Journal of Continuing Educationin the Health Professions are familiar with mul-tiple concepts regarding CME (or CE) aimed atthe individual clinician-learner, although often

set in large group learning sessions. Those con-cepts are meant to be educational or instructive,asserting that the locus of control lies with thepractitioner and that the desirable outcomes ofCE include maintained clinical competency andimproved health care performance. Further, theyare guided by theoretic and practical modelssuch as that of Knowles and colleagues18 andothers19,20 respecting adult learning.

In contrast, guideline implementation,21,22 apotential change agent in the health care system,holds the closing of a measurable gap in care as itsmajor goal. In our scenario, this is the differencebetween pain control in a hospital setting and amore desirable endpoint determined by clinicalpractice guidelines based on best evidence. In thecontext of guideline implementation, the individ-ual practitioner is seen as only one element in acomplex array of forces that include policy, otherhealth care practitioners, patients, family mem-bers, and the health care system itself. These twoperspectives are compared in Table 1.

In addition to the differences in the missionsof the two movements, others exist (Table 1).First, their methods serve to characterize thesetwo constructs: CE begins with a needs assess-ment of its target audience learners, uses educa-tional sessions (even increasingly sophisticatedand interactive ones) to reach them, frequently inlearner-friendly surroundings such as conferencecenters and similar venues. Examples of thesemethods may be found in the rounds and nursingin-servce sessions held in the Australian caseexample given above. In contrast, guidelineimplementation is most often practice based,using methods such as computer-generatedreminders, or extended roles of other health pro-fessionals that are intimately linked to the settingand targeted at all health professionals andpatients (for example, by waiting room educa-tional messages) in that center. Examples are alsofound in the Australian case example. Second,guideline implementation movements are mostoften driven by a quest for best-available evi-dence, a movement fostered by clinical epidemi-

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Continuing Education, Guideline Implementation, and Knowledge Translation


ology, proponents of evidence-based medicine,24

and guideline developers, among others. In con-trast, CE providers (at least to date) generally donot question the sources of evidence presented at

CE events, although increasing efforts may benoted on the part of accreditors to identify com-mercially driven messaging.25,26 Third, there aredifferences in the drivers of both efforts: physician

Table 1 Continuing Education and Guideline Implementation: a comparative table (derived in part from Grol et al)24

CE Guideline Implementation

Mission

Desirable Outcome Maintained or Improved Improved health statusand endpoints competence and clinical

performance

Theoretical constructs Individual Social Individual Social organizational

Target Populations Primarily physicians, other Health care organizations, teams, health professionals, considered with less emphasis on the individ-as individuals. Patients rarely ual learner. Patients and family considered. members may be important targets

of information.

Method

Precursor Needs assessment of learners Best evidence, clinical practice gap, barrier analysis

Interventions Education sessions, resources Academic detailing, reminders, auditand feedback, policy changes

Setting Learning Environment, e.g., Primarily practice environment conference setting

Drivers

Accreditation, individual and Quality improvement, clinical org’l credit systems, commercial accountabilityinterests, internal motivation

Known, less emphasis on evidence- Heavy emphasis on best available based information, increasing clinical evidence (e.g., from sys-distinction between commercially- tematic reviews)driven messages and others

Disciplines interested

Educators, Sociologists, Economists, Health Service Researchers, Psychologists, Accountants, Health Sociologists, Economists, Services Researchers, Business Psychologists, Accountants,Leaders Educators, Business Leaders

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licensure, recertification, credit systems, com-mercial interests, and practitioners’ internalmotivations compel the CE enterprises. In con-trast, guideline implementation is the productof forces emanating from quality improve-ment, patient safety, government and organiza-tional regulatory changes, and the developersof the guidelines themselves. It would appearthat the Australian initiative arises from a mix-ture of both forces.

Finally, it is clear that both processes aremature, well defined, informed by multiple disci-plines (Table 1 lists some), and serve their inter-ests and constituencies reasonably well. Theyeach, however, appear to occupy only one part ofa total picture, aiming to not only create a highlyeducated workforce but also to improve healthcare and health care outcomes. On the one hand,theorists, mostly from the discipline of adult edu-cation, consider the learning and change processon the part of health care practitioners to be themajor subject of importance, amenable to studyand improvement, with the potential of improvedcompetence and health professional perform-ance.18,27–30 On the other hand, quality improve-ment specialists, guideline implementers, healthsystem engineers and analysts, and organiza-tional learning scholars hold their macro, contex-tual, or environmental views as key to thesuccessful implementation of best practice.31

How can we resolve these two perspectives?

Knowledge Translation

One Definition, Many Models

Enter knowledge translation (KT), a constructwith the potential to unite these two perspec-tives. As defined by the Canadian Institutes forHealth Research, KT is “the iterative, timely andeffective process of integrating best evidenceinto the routine practices of patients, practition-ers, health care teams and systems, in order toeffect to optimal healthcare outcomes and tooptimize health care and health care systems.”32

Although the concept of the integration of bestevidence into practice (and the gap that thisprocess intends to fill) is easily grasped, frame-works for such processes come to mind lessreadily, a product of their complex nature and awidely dispersed and fugitive literature.33 Anyeffective KT model requires not only the macro,environmental, or organizational view of guide-line implementation, but also the highly impor-tant, if narrower (“micro”) perspective ofclinicians, their education and continuous pro-fessional development, and their patienst.

KT can lay claim to many theoretical frame-works. Four are presented briefly here. First, mycolleagues at the University of TorontoKnowledge Translation Program attempted tocreate a framework incorporating elements ofphysicians’ progress in adhering to best evidencepractice (awareness, agreement, adoption, andadherence), comparing it to methods of educa-tional interventions that might be characterizedas predisposing (lectures are one illustration),enabling (e.g., patient education materials orflow sheets), and reinforcing (audit and feed-back, for example).34

Second, a more comprehensive model is thatof Lomas et al,33 whose research implementa-tion model is widely known and utilized. Theydescribe a robust, multidimensional construct inwhich external factors—such as the administra-tive, community, and economic environment—the educational milieu, the practitioner, andpatient all play a role, clearly highly importantfactors in knowledge translation issues, and eachexemplified by the case scenario.

Third, combining perspectives of both thelearner and the educator, the model described byFox, Mazmanian, and Putnam5—following in-depth qualitative interviews with over 300 NorthAmerican physicians—affords a rich descriptionof several elements missing in the other modelsof adult learning. In this process, physicians(and one could easily suppose other health pro-fessionals) become aware of a need for changefrom intrapersonal, interpersonal and external

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forces, envisage what that change would looklike, and undertake one or more (often several)steps to accomplish the change. Derived fromadult learning theory and studies of CME, thebenefits of this model are obvious to the educa-tional provider and to the field of KT.

In each of these models, however, the dissem-ination and adoption of new information (such asthat related to patient safety methods) describe alinearity resulting in optimal care—clearly not thecase. A fourth, perhaps a more useful, flexible,and interactive model is that developed by Kitsonand her nursing colleagues.35 They propose threeconstructs: the evidence, the manner of facilita-tion (that is, of communicating the information tothe clinician), and the context in which theseoccur as interactive variables in the understandingof the adoption of evidence. Clearly, Kitson’s con-struct, in which variables in a KT equation can beseen to play a role, is a step forward. Where fac-tors in all or some of these three domains lendthemselves to the acquisition of new evidence,Kitson et al state that adoption is more readilyobserved.35 Yet, there are problems with thismodel as well: where do considerations of theadult clinician-learner lie? In fact, it is easy toobserve that all these models are in some wayflawed. The models proposed by Davis and byFox36 and their colleagues assume only the nar-row perspective of the learner in the context ofCE32; Lomas’ model,33 while clearly comprehen-sive and holistic, is highly linear26-29; Kitson’s useof variables is useful but incomplete.35

What, if anything, are we to make of thesedefinitional and conceptual issues? Which, ifany, model fits best? How are we to implementKT strategies? What are the implications of thisfor CE providers and educators?

Discussion

Next Steps in Solving the KT Puzzle

First, what practical implications are there for theCME provider and scholar in this discussion of

concepts? It appears, at a minimum, that we needto add the perspective of the adult learner-clini-cian to the mix of issues proposed by guidelineimplementation and their related “cousins,” qual-ity improvement and patient safety. Here, theInstitute of Medicine call to action, Crossing theQuality Chasm,37 and its health professionaleducation response38 possess several curricularrecommendations to address needs of the learner-clinician: training for health professionals towork as teams, teaching skills in informatics, rec-ognizing and dealing with the overabundance ofinformation and evidence, and increasing theattention to improvement in quality.39-43 Theseissues alone can occupy the career and interest,and set the agenda for, many CME providers.

Second, we must couple whatever strategieswe create in a cohesive and testable model. At thevery least, this process calls for action at the indi-vidual and the organizational levels. Grol andGrimshaw’s 1999 article44 outlines tools (feed-back and audit, opinion leaders, educationalinterventions, etc.) to effect change and calls forlarge-scale organizational changes by which thiscan happen. There are some problems inherent inthis approach, however, for example, the minuteeffect size of any intervention when consideredby itself,22 the consideration by CME providersthat all evidence or information is the same, andthe lack of overall organizational change, to namea few. There are as yet undeveloped and untestedmore robust models to assist us in understandingclinical performance change and patient safety;we must create, embrace, and test them.

Third, it is apparent that this description ofKT, however comprehensive, is still only a partof the story. In this essay, descriptions of guide-line implementation, knowledge translation, andto some extent, CE represent “convenience sam-ples” of models and definitions only briefly pre-sented. In addition, they—and in particular, thephrase “knowledge translation”—run the risk ofconfusing and muddying our understanding.Here, for example, we need to differentiate theconcept of transformational learning (in which

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Lessons for Practice

• Continuing education is conceptuallyrooted in adult education, and guide-line implementation borrows from theliterature of health services, qualityimprovement, and patient safety.

• Neither field fully covers the complexarray of issues inherent in the adoptionof best evidence and the achievementof best health outcomes.

• Knowledge translation offers an overar-ching construct for achieving the adop-tion of best evidence, leading to besthealth outcomes.

learners change how they know) from that ofknowledge translation (in which health care sys-tems and individuals adopt and apply best clini-cal evidence).45 Further, issues such as thosearising from a consideration of the clinical caregap require an understanding of both micro (theclinician-learner) and macro (system) perspec-tives to be fully understood and ultimately opti-mized. Finally, they also require a morecomplete embracing of the patient in thiseffort––for example, the child with pain in ourcase scenario, the ultimate recipient of the bene-fits related to closing the clinical care gap.

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