liz stirling and jacqueline tetroe

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

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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

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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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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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What is NOT KT?

For example, KT is NOT:

Continuing Medical Education

Continuing Professional Development

Translational Research

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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

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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

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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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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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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

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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.

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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

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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

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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

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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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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.

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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

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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

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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

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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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Knowledge to Action CycleKnowledge to Action – Graham et al 2006

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Knowledge to Action – Graham et al 2006

How was this model derived?

• The Knowledge Creation “funnel”• The Action Cycle

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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.

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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

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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

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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

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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

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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

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Action categories continued…

• Tailor/develop intervention• Link(age)• Implement• Evaluate

• Develop evaluation plan• Pilot test• Evaluate the process• Evaluate outcomes

• Maintain change• Disseminate

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Knowledge to Action CycleKnowledge to Action – Graham et al 2006

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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…

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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

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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

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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

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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.

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• 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

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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

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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

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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

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wound care

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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

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http://www.cihr-irsc.gc.ca/e/30669.html

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

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Leg Ulcers are:• Common, costly, complex• Chronic, recurring• Debilitating, isolating condition• 80% care reported to be community-based,

delivered by nurses

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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

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• High level evidence for assessment and management of venous ulcers

• Numerous international Clinical Practice Guidelines available

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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


interventions

Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use

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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)

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Knowledge inquiry

Knowledge synthesis

Knowledge tools/

products

Tailo

ring

kno

wle

dge

Knowledge Creation

Identify Problem



Assess barriers

to knowledge

use


interventions

Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use

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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

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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

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Knowledge inquiry

Knowledge synthesis

Knowledge tools/

products

Tailo

ring

kno

wle

dge

Knowledge Creation

Identify Problem



Assess barriers

to knowledge use


interventions

Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use

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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

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Knowledge inquiry

Knowledge synthesis

Knowledge tools/

products

Tailo

ring

kno

wle

dge

Knowledge Creation

Identify Problem



Assess barriers

to knowledge use


interventions

Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use

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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)


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Knowledge inquiry

Knowledge synthesis

Knowledge tools/

products

Tailo

ring

kno

wle

dge

Knowledge Creation

Identify Problem



Assess barriers

to knowledge use


interventions

Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use

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Evaluation of outcomes

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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

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Knowledge inquiry

Knowledge synthesis

Knowledge tools/

products

Tailo

ring

kno

wle

dge

Knowledge Creation

Identify Problem



Assess barriers

to knowledge use


interventions

Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use

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Sustainability still under investigation:

• Protocol expanded to 3 other regions

• RCT underway of home vs clinic care

• RCT underway of two compression technologies

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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

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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

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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

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liz stirling and jacqueline tetroe

Documents

knowledge translationwhat

knowledge translationhow

knowledge management

knowledge utilization

knowledge translationcontext

knowledge dissemination

knowledge translation

sound application of