Teaching Evidence Assimilation for Collaborative Health Care

Capacity Building for Knowledge Based Improvement

Peter Wyer MDChair, Section on Evidence Based Health Care

New York Academy of Medicine

ACKNOWLEDGEMENTSTEACH TEAM LIBRARIANS INTERNATIONAL ADVISORS NYAM TEAM

Saadia Akhtar Louise Falzon Ian Graham Eileen Budd

Barney Eskin Pat Gallagher Dave Davis Donna Fingerhut

Eddy Lang Pattie Mongelia John Lavis Francine Leinhardt

Judy Honig Dorice Vieira Sharon Straus Sharon Ching

Aleksandr Tichter Jamie Graham Yngve Falck-Ytter Tawana Wright

Suzana Alves Silva Yingting Zhang Claudette Dykes-Brown

Arlene Smaldone

Craig Umscheid

TJ Jirasevijinda

Stewart Wright

TEACHING EVIDENCE ASSIMILATION FOR COLLABORATIVE HEALTHCARE

DISCLOSURES

No Faculty Disclosures Declared

Generous Donation of Electronic Resources: Annals of Internal Medicine (ACP Journal Club)

BMJ Group (Clinical Evidence, Evidence Based Nursing)EBSCO (Dynamed, CINAHL)

McGraw-Hill-JAMA (JAMA Evidence) Wolters Kluwer (OVID, UpToDate)

TEACHING EVIDENCE ASSIMILATION FOR COLLABORATIVE HEALTHCARE

Who Are We?The Section on Evidence Based Health Care

at the New York Academy of Medicine

Objectives:

• Patient centered care

• Responsiveness to change

• Knowledge based improvement

Capacity Building

TEACHING (EVIDENCE ASSIMILATION)

• Evidence Based Practice

• Clinical Policies, Recommendations

• Knowledge Translation/Implementation

TEACHING (EVIDENCE ASSIMILATION)

• Evidence Based Practice

• Clinical Policies, Recommendations

• Knowledge Translation/Implementation

• Individual patients

• Populations

• Systems

TEACHING (EVIDENCE ASSIMILATION)

• Basic, or Foundational, Skills

• Reviews, Appraising/adapting guidelines

• Knowledge creation, implementation

• Individual patients

• Populations

• Systems

TEACHING (EVIDENCE ASSIMILATION)

• Basic, or Foundational, Skills

• Reviews, Appraising/adapting guidelines

• Knowledge creation, implementation

LEVEL 1

LEVEL 2

LEVEL 3

Level 1

• Constructed priorities and preferences• Road Map defining evidence literacy• Narrative, clinical and epidemiological skills

Level 2

• Clinical policies and recommendations• Specific health care settings• Guideline appraisal and adaptation• The GRADE system• Building in adaptability, actionability

Level 3

• Team based problem definition• Gathering ‘internal’ + ‘external’ evidence• Consider health services, implementation research• Monitoring measurable and sustainable impact • Maintaining currency

A Common Skill Matrix Across Dimensions

• Problem delineation• Formulating information needs• Finding the most relevant evidence• Appraising evidence quality and importance• Evaluating relevance, interpreting applicability• Assimilation

(Teaching) Evidence Assimilation

Evidence from research: Lead protagonist or supporting cast?

• Scientifically informed individualized care• Evidence-informed clinical policies • Knowledge-based quality improvement• The narrative dimension

Scientifically Informed Clinical Practice Within Organized Health

Care Settings

Management

Individual patient care

Clinical policydevelopment

Implementation

Executive

Specialties

Care delivery

Practitioners Team

Patients

The TEACH Experience

Clinical/Administrative• Problem driven• Comprehensive team• QI present, subordinated• Systematic approach

– Lit review– Chart review– Baseline outcomes

• 18 months to launch• Prize winning results

Quality Improvement• Intervention driven• Limited team• QI operationally in charge• Shortcuts

– Direct planning to implement– No baseline data

• 6 months to launch• Modest results

DRIVERS

Attributes “QI” vs “KT”• Process OC• Error• Variation• Short turn around• QI team• Industrial standards

• Patient-centered OC• Unnecessary care • Innovation• Intermediate turn around• Organizational engagement• Scientific standards

KT or QI

Hence: EBM + QI ≠ KBI

Quality Improvement/TQM

Knowledge Translation

Process Outcomes(Error reductionVariation decrease)

Clinical Outcomes(Adoption of innovation‘De-adoption’ of unnecessary care)

Internal Knowledge

External Knowledge

MODE CONTENT EXCHANGE

Nonaka: Organizational Kowledge Creation

Comparative Effectiveness and Practice Based Research: The Frontiers of “EBP”

• The importance of local, or ‘internal’ evidence • The importance of practice experience• PBR-blurring the boundary between ‘research’

and ‘practice’• Classical clinical research remains valuable,

frequently crucial, but nontheless indirect