Webinar 1: Introduction to Knowledge Translation and Implementation Science
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his is the first in a series of interactive webinars designed to build capacity in the basic principles of knowledge translation and implementation science. WATCH-ON DEMAND: https://goo.gl/hnp8gi
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Webinar 1: Introduction to Knowledge Translation and Implementation Science
- 1. www.ohri.ca | Affiliated with • Affilié à CPSI National Webinar Series Knowledge Translation and Implementation Science Education Series Webinar 1: Introduction to Knowledge Translation and Implementation Science Justin Presseau Scientist, OHRI Assistant Professor, uOttawa @JPresseau jpresseau@ohri.ca Jeremy Grimshaw Senior Scientist, OHRI Full Professor, uOttawa @GrimshawJeremy jgrimshaw@ohri.ca Centre for Implementation Research
- 2. Overview ▶ Faculty introductions ▶ Overview of the webinar series ▶ Historical roots and rationale for Knowledge Translation and Implementation Science ▶ Overview of models, theories and frameworks and how they can be used to implement and evaluate patient safety initiatives
- 3. About us Jeremy Grimshaw • Trained as a family doctor in the UK • PhD in health services research • Developed implementation research program in UK • Moved to Canada in 2002 • 25+years in implementation/KT research Justin Presseau • Trained as a health psychologist in UK • PhD in psychology • Focused on behavioural science applied to implementation research • Moved (back) to Canada in 2015 • 10+years in implementation/KT research
- 4. About us – What we do • Professional and organizational behaviour change • Improving technical aspects of health care • How do we ensure that patients get the right (evidence based) treatments when they need them most • Focus on various populations of health care providers and the organizations that they work in
- 5. Centre for Implementation Research at the Ottawa Hospital ▶ Unique interdisciplinary team harnessing and developing contemporary approaches to improving health care. 14 Core faculty: • Jamie Brehaut (cognitive psychology) • Ian Graham (medical sociology) • Jeremy Grimshaw (health services research) • David Moher (epidemiology and biostatistics) • Justin Presseau (health psychology) • Janet Squires (nursing and KT) • Dawn Stacey (nursing and shared decision making) • Monica Taljaard (biostatistics) • Kednapa Thavorn (health economics) • Angel Arnaout (surgical oncology) • Sylvain Boet (medical education) • Jill Francis (health and social psychology) • Noah Ivers (clinical epidemiology and family medicine) • Holly Witteman (human factors engineering) ohri.ca/cir
- 6. Background ▶ Ensuring patient safety remains a high priority for healthcare systems, organisations and providers ▶ The Canadian Patient Safety Institute (CPSI) has been at the forefront of efforts to promote safety in Canadian Healthcare settings and has achieved substantial improvements in patient safety ▶ However, there remain substantial challenges to implement patient safety practices ▶ SHIFT to Safety, a platform of CPSI, is launching a new initiative to promote the use of behavioral approaches in patient safety initiatives
- 7. A behavioural perspective to KT and IS ▶ Successful implementation of patient safety programs needs key actors (patients, healthcare providers, managers and policy makers) to change their behaviours and/or decisions whilst working in the complex (ordered chaos) of health care environments ▶ There is a substantial evidence base in behavioural sciences that can support the development of patient safety programs and increase the likelihood of success
- 8. The webinar series – overview ▶ Webinar 1: Introduction to KT and Implementation Science ▶ Webinar 2: Knowledge creation and synthesis ▶ Webinar 3: Who needs to do what differently to promote implementation? ▶ Webinar 4: Identifying barriers and enablers, and determinants, in theory ▶ Webinar 5: Identifying barriers and enablers, and determinants, in practice ▶ Webinar 6: Selecting and evaluating strategies to address barriers and enablers Aim: build capacity in the basic principles and practice of Knowledge Translation and Implementation Science to inform your own patient safety initiatives
- 9. Historical roots to KT and IS 1962 1973 70s/80s 2000s Pressman & Wildavsky Implementation – launches research on policy implementation Research on research and knowledge use/utilization Implementation science, KT take off 1992 EBM/EBP Slide credit: Per Nilsen
- 10. Historical roots to KT and IS ▶ Consistent evidence of failure to translate research findings into clinical practice • 30-40% patients do not get treatments of proven effectiveness • 20–25% patients get care that is not needed or potentially harmful ▶ Suggests that implementation of research findings is fundamental challenge for healthcare systems to optimise care, outcomes and costs Schuster (1998). Milbank Memorial Quarterly Grol (2001). Med Care
- 11. ▶ “[t]he scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice”1 ▶ Implementation is a human enterprise that can be studied to understand and improve implementation approaches ▶ The interdisciplinary scientific study of : • Determinants, processes and outcomes of implementation in healthcare • Methods for promoting the uptake of research evidence into routine practice in clinical, community and policy contexts • Broad range of disciplines and forms of enquiry needed ▶ Goal: develop a generalizable empirical and theoretical basis to optimize implementation activities to improve the healthcare provided to patients and the public What is Implementation Science? 1Eccles and Mittman (2006) Implementation Science
- 12. A rose by any other name would smell as sweet applied health research capacity building co-optation - cooperation - competing diffusion* dissemination* getting knowledge into practice impact Implementation* knowledge communication knowledge cycle knowledge exchange knowledge management knowledge translation knowledge mobilization knowledge transfer linkage and exchange popularization of research, research into practice research mediation research transfer research translation science communication teaching “third mission” translational research transmission utilization Tetroe et al (2008) assessed how 33 funding agencies from OZ, Canada, France, the Netherlands, Scandinavia, the UK and the US describe implementation: In the USA: Dissemination and Implementation (D&I) In Canada: Knowledge Translation (KT) In the UK: Improvement Science / Implementation Science Increasing cohesion towards ‘Implementation Science’
- 13. A new kid on the block ▶ Implementation science is a relatively new field in health research ▶ Inherently interdisciplinary ▶ Wide range of disciplines need to be engaged • Clinical • Health services research • Social sciences • Design and engineering • Informatics • Methodologists • Health Psychologists: behaviour change specialists ▶ Broad range of forms of enquiry needed
- 14. Core research activities in implementation science ▶ Knowledge synthesis (what do we know about the effectiveness of different implementation approaches); ▶ Identification of implementation failures; ▶ Development of methods to assess barriers and facilitators to implementation; ▶ Development of implementation interventions; ▶ Development of the methods for optimising implementation interventions; ▶ Evaluations of the effectiveness and efficiency of implementation interventions; • Process, fidelity and outcome evaluation ▶ Sustainability and scalability of implementation interventions; ▶ Development of implementation science theory; and ▶ Development of implementation science research methods.
- 15. How do healthcare organizations implement change? ▶Develop and disseminate clinical practice guidelines
- 16. Affiliated with • Affilié à Favourite solutions If you have a hammer, everything looks like nail
- 17. Develop Internal solutions Most frequently used model of change in the literature: ISLAGIATT model (It Seemed Like A Good Idea At The Time) An expensive version of trial and error
- 18. Affiliated with • Affilié à ▶All of these solutions work some of the time. ▶None work all of the time. ▶It is unclear when they do work whether they maximally improve practice. ▶It is unclear when they do work whether they represent the most efficient use of scarce health care quality improvement resources.l Current situation
- 19. Inefficient Does not build on what we already know • Can lead to re-inventing the round wheel (waste of resources) • Can lead to re-inventing the square wheel (repeating what does not work) Insufficient • May miss important factors Unscientific • Based on implicit idea of what drives change (may or may not be supported by evidence) • Implicit ideas undermine replication and knowledge accumulation Some potential problems with ISLAGIATT…
- 20. ▶Many organizational responses have not achieved optimal care despite considerable investments ▶Most approaches to implementing are more often based on ‘hunches’ and ‘ISLAGIATT’ than on scientific evidence We owe it to patients and the public to do better Evidence based practice should be complemented by evidence based implementation Richard Grol (1997, BMJ) How do healthcare organizations address this issue?
- 21. Beyond ISLAGIATT: Theories, models & frameworks used in Implementation Science ▶Last 10 years: increased recognition of value of theory to build cumulative evidence ▶Now draws on other disciplines as well as developed new integrative theories, models and frameworks within IS itself Nilsen 2015
- 22. ▶Healthcare-associated infections are one of the top 10 causes of hospital deaths worldwide • Affects 10% of all patients in acute-care hospitals ▶Physician hand hygiene compliance is an international problem • Average reported compliance rate: 49-57% ▶Reasons for poor compliance not well understood ▶Our case study: assume we want to develop a patient safety initiative to improve physician hand hygiene A Case Study to inform our overview: Physician hand hygiene Guiding principle Need to understand the problem before jumping to solutions
- 23. Beyond ISLAGIATT: Theories, models & frameworks used in Implementation Science Nilsen 2015 First, select an overarching process model to guide the steps to developing an initiative
- 24. Key Process model 1: KTA Framework High level models describing steps for moving evidence into practice Knowledge to Action Framework Graham et al (2006) Focus on the Knowledge Creation funnel in more detail in Webinar 2 Focus on identifying the problem in Webinar 3 Focus on barriers/enablers in Webinar 4-5 Focus on selecting strategies and evaluation in Webinar 6
- 25. Step 1: Who needs to do what, differently? Whose behaviour need to change, and which behaviours? What is the evidence supporting this? Step 2: What factors determine whether or not they do it? What are the barriers and enablers? Step 3: Which strategies can be effectively used to target those factors? Which behaviour change techniques are best suited to specifically target the identified barriers and enablers Step 4: How can we robustly measure the outcome? 1 2 3 4 28 (French et al., 2012) Key Process model 2: The French Model We will be focusing on each aspect of the French Model in more detail in Webinars 3 to 6
- 26. Beyond ISLAGIATT: Theories, models & frameworks used in Implementation Science Nilsen 2015
- 27. Determinant frameworks: Which barriers and enablers that influence implementation ▶Not short on such frameworks: at least 12, with 57 unique determinants1 A few predominant frameworks that synthesize many determinants and inform barriers/enablers assessments ▶Ferlie & Shortell levels of change2 ▶CFIR: Consolidated Framework for Implementation Research3 ▶TDF: Theoretical Domains Framework4,5,6 • Sometimes both combined7 1Flottorp et al 2012; 2Ferlie & Shortell 2001; 3Damschroder et al 2009; 4Michie et al 2005; 5Cane et al 2012; 6Atkins et al 2017; 7Birken et al 2017 We will be focusing on the TDF in more detail in Webinar 4 and 5
- 28. Theoretical Domains Framework (TDF) Knowledge Skills Social/professional role and identity Beliefs about capabilities Optimism Beliefs about consequences Reinforcement Intention Goals Memory, attention & decision processes Environmental context and resources Social Influences Emotion
- 29. Theoretical Domains Framework (TDF) Knowledge Skills Social/professional role and identity Beliefs about capabilities Optimism Beliefs about consequences Reinforcement Intention Goals Memory, attention & decision processes Environmental context and resources Social Influences Emotion • Key informant interviews with 42 staff physicians and residents in Medicine, Surgery • Two focus groups with four institutional hand hygiene “experts”: hand hygiene auditors, infection prevention and control professionals, and Senior Management • Observation of hand hygiene and audits on inpatient Medicine and Surgery units Key Domains (bold)
- 30. Theoretical Domains Framework (TDF) Knowledge Skills Social/professional role and identity Beliefs about capabilities Optimism Beliefs about consequences Reinforcement Intention Goals Memory, attention & decision processes Environmental context and resources Social Influences Emotion Behavioural Regulation • Important TDF domains were prioritized with team input, and mapped to known effective behaviour change techniques • Intervention focused on five prioritized domains, considering feasibility in our environment, and acceptability to the “actors” • Knowledge • Skills • Beliefs about consequences • Memory, attention and decision processes • Social influences Intervention development
- 31. Beyond ISLAGIATT: Theories, models & frameworks used in Implementation Science Nilsen 2015
- 32. Evaluation Frameworks: What to evaluate ▶RE-AIM (Glasgow 1999) • Reach • Effectiveness • Adoption • Implementation • Maintenance We will be focusing on evaluation in more detail in Webinar 6
- 33. Step 1 Who needs to do what, differently? Step 2 What factors determine whether or not they do it? Step 3 Which strategies can be effectively used to target those factors? Step 4 How can we robustly measure the outcome? (French et al., 2012) Once barriers identified, which strategies to select? ✓ Principle: no magic bullets ✓ Select strategies that work best for specific identified barriers/enablers ✓ Be explicit (using theories and taxonomies) to ensure clarity and replication ✓ Distinguish ‘what’ you deliver from ‘how’ it is delivered 36 We will be focusing on selecting change strategies and techniques in more detail in Webinar 6
- 34. Theoretical Domains Framework (TDF) Knowledge Skills Social/professional role and identity Beliefs about capabilities Optimism Beliefs about consequences Reinforcement Intention Goals Memory, attention & decision processes Environmental context and resources Social Influences Emotion Behavioural Regulation Based on assessment of barriers, resources, practical aspects of implementation: Medicine: • Two slides for resident orientation • Four x 2 minute sessions during stewardship rounds • Glo GermTM demonstration Surgery: • 10 minutes at resident half day, with Glo GermTM • 10 minutes at staff division meeting Intervention delivery and evaluation
- 36. Summary and initial take home messages ▶ Patient safety remains major concern in healthcare systems ▶ Don’t jump straight to solutions: Developing solutions before understanding the problem risks developing elegant solutions to non- problems ▶ No magic bullets: no strategy works in all instances ▶ Implementation Science is the scientific study of the determinants, processes and outcomes of implementation ▶ Successful implementation of patient safety change programs requires actors to change their behaviour(s) ▶ Insights from behavioural science can help optimise change programs and increase their likelihood of success ▶ Drawing upon IS approaches can avoid the pitfalls of ISLAGIATT approaches and promote a shared understanding of what works to improve patient safety
- 37. Next Webinar Knowledge creation and synthesis March 21st, 2018 noon EST Lead: Jeremy In the meantime… Please send us examples of your own planned/ongoing patient safety initiatives so that we can directly inform our examples in the next webinars Send to: jpresseau@ohri.ca
- 38. www.ohri.ca | Affiliated with • Affilié à Justin Presseau Scientist, OHRI Assistant Professor, uOttawa @JPresseau jpresseau@ohri.ca Jeremy Grimshaw Senior Scientist, OHRI Full Professor, uOttawa @GrimshawJeremy jgrimshaw@ohri.ca Centre for Implementation Research Thank you