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Applying Evidence in Practice
André Bussières DC, PhD30 April 2015
EDITH STRAUSS INTERACTION DAY
Overview
Clinical decision making in Rehab
Knowledge translation
Apply Evidence in Practice
Evaluating evidence use
Individual clinical expertise
(experience, judgment)
Client’s values and expectations
Best available external clinical
evidence from systematic
research
Clinical Decision Making in Rehabilitation
Circumstances/clinical contextClinical decision
Literature search
Overview
Clinical decision making in Rehab
Knowledge translation
Apply Evidence in Practice
Evaluating evidence use
MonitorKnowledge
Use
SustainKnowledge
Use
EvaluateOutcomes
AdaptKnowledge
to Local Context
AssessBarriers/Facilitators to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Products/Tools
Synthesis
Knowledge Inquiry
KNOWLEDGE CREATION
Conceptual framework CIHR model
(Graham 2007)
KT: three conceptually distinct types (Lomas’ taxonomy, 1993)
• Diffusion (“just let it happen”): passive, largely unplanned uncontrolled, primarily horizontal, mediated by peers • Peer-reviewed publications, academic/research conferences
• Dissemination (“make it happen”): targeted and tailored findings/messages to a specific audience• What, to whom, how, and with what effect?• (Theory-based) interviews/focus groups/surveys, descriptive • User-driven strategy, media engagement, knowledge broker• Network or communities of practice
• Implementation (“use robust methods”): systematic efforts to encourage adoption of research evidence by identifying & overcoming barriers to their use• Intervention mapping (theory driven), cluster RCTs, Evaluation
Planning Dissemination and Implementation
2.5% 13.5% 34% 34% 16%
Ro
gers
Dif
fusi
on
an
d In
no
vati
on
Rogers Diffusion and Innovation (2003)
European Foundation for Quality Management (EFQM) Excellence Model: http://www.efqm.org
Knowledge Translation: The big picture
RADAR - Structured approach for questioning performance
Determine the Results it is aiming to achieve as part of its strategy
Plan and develop an integrated set of sound Approaches to deliver the required results both now and in the future
Deploy the approaches in a systematic way to ensure implementation
Assess and Refine the deployed approaches based on monitoring and analysis of the results achieved and ongoing learning activities.
Overview
Clinical decision making in Rehab
Knowledge translation
Apply Evidence in Practice
Evaluating evidence use
Identify a clinical problem to be addressed
• Why do we need this intervention?(High prevalence, high burden, under or overuse; new evidence)
• Who will benefit from this intervention?(Target audience)
• What are the goals of this intervention?(Anticipated outcome)
• What is considered as a successful implementation?(Indicators of success)
MonitorKnowledge
Use
SustainKnowledge
Use
EvaluateOutcomes
AdaptKnowledge
to Local Context
AssessBarriers/Facilitators to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify ProblemIdentify, Review,
Select Knowledge
KNOWLEDGE CREATION
Conceptual framework CIHR model (Graham 2007)
Identify knowledge users
• Who are the end users: patients, health professionals, managers
• Eligibility: inclusion/exclusion criteria?
Planning practice change
Resources needed for implementing intervention• Who is the project leader?
• Stakeholders to be involved?
Individuals (managers, patients, etc.) who will facilitate implementation
• Material needed? (equipment, technology, space)
• Human resources? (content expert, IT support)
• Organizational? (protected time)
• Costs? (adapting environment, training, equipment)
Engaging knowledge users and stakeholders
• How will you involve and maintain engagement with end-users and stakeholders?
• Procedures
• Incentives (continuing edu., certificate of completion, financial, etc.)
• Mode of communication (email, printed; reminders)
• Meetings (face-to-face, phone, e-platform)
• etc.
Defining the content of your intervention
• Describe your intervention (e.g. functional electrical stimulation, manual therapy, mirror therapy)
• Specific guidelines/protocols for administering this intervention?Dosage (3 times/week x 2 weeks)
Mode of administration
Benefits/risks
Minimal competencies needed
Patients preference and values
How good is the proposed intervention?
Assign level of evidence Appraise quality of evidence
Evaluate clinical applicability of evidence
Pre-Appraised
How well does the intervention fit with the practice setting and target group?
1. Assess: Workflow, work practices, clinical processes, tasks?
2. Adapt: Modify the intervention to fit with your practice setting and/or target group
Designing a knowledge translation (KT) strategy
Specify the objectives
Develop a practice change plan
Highlight facilitators and barriers to practice change
What are the objectives of your KT strategy?
• Change in knowledge, skills, attitudes, self-confidence, etc.
• Change in the actual practice (professional behavior)
• Change in patient health outcomes
Proposed practice change:
e.g. Implement treadmill training for
children with brain injury
Evidence on which it is based:
e.g. Green light evidence demonstrates
improved _____ outcomes.
Expected impact of clinical change
(Evaluation):
Key Messages (from traffic lighted
synthesis, CAT or education session):
Practice Change Plan
http://www.childdevelopment.ca/Evidencecentre/EvidenceBasedPractice.aspx
Developing An Action Plan
Category Facilitators Planned Action Key People Timeline Date Completed
Human Resources
e.g. local expert e.g. mentoring
Material Resources
e.g. space to carry out intervention
e.g. ensure
space use compatible with current practice
Organisational
Resources
Other
Highlight Facilitators of Practice Change
Created April 23, 2012 by Stephanie Glegg & Alyssa Barrie
http://www.childdevelopment.ca/Evidencecentre/EvidenceBasedPractice.aspx
Address Barriers of Practice ChangeConsideration Barrier Planned Action Key People Timeline Date Completed
Generalisability1
Sample not exactly representative of
our clinical population1,2
e.g. Measure client outcomes
when intervention is used
Social Acceptability1
Lack of clinician awareness/interest3
e.g. Develop a KT Plan
Organisational
Capacity1
Equipment required
not accessible2
Equipment not affordable1,2
Intervention needs
adapting to suit our context1
Professional
Capacity
Lack of knowledge
or skills to carry out the intervention1
e.g. Training
course/online module, etc e.g. KT Plan
Additional resources required
to facilitate implementation
e.g. Develop or adapt ____
resources for
[target stakeholder]
KT Plan
Reproducibility Treatment intensity
not feasible2,4
e.g. Modify treatment
intensity and
measure client outcomes
Created April 23, 2012 by S. Glegg & A. Barrie
Developing An Action Plan
http://www.childdevelopment.ca/Evidencecentre/EvidenceBasedPractice.aspx
Theoretical Domains Framework (McKenzie, French 2011)
Michie (2005). Journal of Quality and Safety in Health Care.
Knowledge
Professional role and identity
Beliefs about capabilities
Beliefs about consequences
Motivation and goals
Environmentalcontext andresources
Social influences
Emotion
Behaviouralregulation
Nature of the behaviours
Memory and decision
processes
Skills
Designing a knowledge translation (KT) strategy
1. What is the message?
2. Who is the audience?
3. Who is the messenger?
4. What is the transfer method?
5. What is the expected outcome?
(Gagliardi, 2011, Katner 2011, Readon-IWH 2006)
MonitorKnowledge
Use
SustainKnowledge
Use
EvaluateOutcomes
AdaptKnowledge
to Local Context
AssessBarriers/Facilitators
to knowledge Use
Select, Tailor,Implement
Interventions
Identify ProblemIdentify, Review,
Select Knowledge
KNOWLEDGE CREATION
Conceptual framework CIHR model (Graham 2007)
1. What is the message?
• Key message(s) for your end-users/stakeholders
• How will you deliver the key messages?
(e.g. email, newsletter, official meetings, informal meetings, etc.)
• At what frequency will you deliver the strategy (or key messages)?
2. Who is your audience?
3. Who is the messenger?
• Content expert
• Health care professional
• Champion/opinion leader (health provider, known figure)
• Patient advocate
• Manager/policy maker
4a. What is the KT strategy?
Professional strategies:• Didactic lecture, conferences, workshops• Printed educational material (guidelines, policy brief, etc.)• Outreach visits• Knowledge broker• Audits & Feedback• Reminders• Etc.
Organizational; Financial strategies:
4b. How will the strategy be delivered
When, how frequently, for how long?
Any supporting documents? (e.g. articles, guidelines, lecture recording, pamphlets)
Estimated costs for developing and delivering your strategy?
Overview
Clinical decision making in Rehab
Knowledge translation
Apply Evidence in Practice
Evaluating evidence use
5. Practice Change Evaluation Plan1. Goal: Implementing the Start Back Screening Tool
Action Targeted Due Date
Status/Date Completed
Responsibility
1. Identify/prioritize interventions and/or assessments to change
April 30, 2015 Completed April 30, 2015
Group, process facilitated by KB/leader
2. Action plan (objectives, facilitators, barriers to change)
[date] In Progress Group
3. Designing your KT strategy [date] In Progress Small work group of clinicians
4. Monitoring/Evaluating practice [date] Not yet started Small work group of clinicians
Monitoring (progress/follow-up):
Monitoring adherence to the intervention
a. Indicators of adherence (e.g. frequency of use, appropriateness of care)
b. Evaluating adherence (e.g. chart audit, written/electronic health records)
Monitor adherence to your KT strategy
a. Indicators of adherence (e.g. attendance rate to workshop)
b. Evaluating success of KT strategy (e.g. quiz)
Evaluating impact: did it work?
Measuring the effectiveness of your intervention?
• Patient reported outcome measures (PROMIS: www.nihpromis.org/)
Measuring the effectiveness of your KT strategy?
• Uptake/changes (based on pre-identified indicators of success): • In provider
• knowledge, skills, attitudes, self-confidence, satisfaction, etc• in actual practice (x-ray utilization rate, prescribing, etc.)
• in patient health outcomes• In organization structure (wait lists, length of stay and costs)
Reflecting on the implementation
• Feedback (challenges and lessons learned) to end-users/stakeholders about:• Intervention
• KT strategy
• How will the feedback be shared? (e.g. questionnaire, focus group, emails, newsletters)
Ressources
• KT Canada: http://ktclearinghouse.ca/
• Heath Systems Evidence: http://www.mcmasterhealthforum.org/hse/
• Rx-For-Change Database (CADTH): https://www.cadth.ca/resources/rx-for-change/database/browse
• Cochrane Effective Practice and Organization of Care (EPOC): http://epoc.cochrane.org/our-reviews
Thank you
‘‘THE PESSIMIST COMPLAINS ABOUT THE WIND;THE OPTIMIST EXPECTS IT TO CHANGE;
THE REALIST ADJUSTS THE SAILS.’’
William A Ward
• Step 1: Write a focused answerable clinical question
• Step 2: Conduct a comprehensive and efficient search for information
• Step 3: Determine where your best evidence fits on the Hierarchy of Evidence
• Step 4: Apply Evidence to Practice
• Step 5: Evaluating evidence use
http://www.childdevelopment.ca/Evidencecentre.aspx
Child Development & Rehabilitation- Joint project of Sunny Hill Health Centre For Children and the Children and Youth with Special
Needs area of British Columbia's Ministry of Children and Family Development. Funded by the Sunny Hill Foundation:
http://www.childdevelopment.ca/Evidencecentre/EvidenceBasedPractice.aspx
Your feedback?
1. What was your experience like with using the Implementation Plan Worksheet?
2. What sections of the Worksheet were more challenging?
3. Are there any potential barriers in your setting that may challenge the application of this implementation plan?
4. Following this experience, do you feel more confident with designing your own implementation plan?
