Promoting partnership in knowledge translation: the NIHR CLAHRC approach

Kate Gerrish, PhD, RNProfessor of Nursing ResearchUniversity of Sheffield/Sheffield Teaching Hospitals NHS Foundation Trust

NIHR CLAHRC for South Yorkshire

5 year NIHR funded programme of applied research and implementation of research focusing on self management and self care for long-term conditions

BarnsleyDoncaster

Rotherham Sheffield

NIHR Collaboration for Leadership in Applied Research and Care for South Yorkshire (CLAHRC)

CLAHRC – key features

£20 million over 5 years – £10m from NIHR with matched funding from partners

Collaborative between universities, NHS commissioners and healthcare providers

Partnership working to support capacity building for research and implementation

Self-management and self-care of

long term conditions

NIHR CLAHRC for South Yorkshire

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pplication

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ies

Genetics

Tele-health

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User-centred

Healthcare Design

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Achieving translation

Translating knowledge

intoaction

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Aim: To develop step change in the way research findings are implemented in practice • by …

• trialling and evaluating innovative implementation strategies to facilitate evidence-based care

• in order to …• enhance service quality,

contribute towards improving patient outcomes, and/or increase patient safety

Translating knowledge into action (TK2A)

Develop, pilot and evaluate implementation strategies to promote evidence-based practice in response to identified service priorities

Disseminate successful initiatives across CLAHRC partnership

Develop the capacity of health care professionals to engage in KT implementation & KT research

Establish collaborations between NHS and academic partners to facilitate knowledge translation

Contribute to the field of implementation science

TK2A objectives

Contribution to implementation science

Contribute new knowledge to the field of KT• Understanding the trajectory of complex innovation in

healthcare settingsTest and further refine existing theoretical frameworks for KT• Knowledge to Action - Graham et al 2005• Consolidated framework for implementation research -

Damschroeder 2009Contribute to the further development of key concepts in KT• Knowledge brokering• Boundary spanning

Undertake KT evaluation• Knowledge translation case book• Evaluation of After Action Review methodology

Knowledge translation

KT is a dynamic, iterative process that includes the synthesis, dissemination, exchange, and ethically sound application of knowledge within a complex system of interactions among researchers and users with the intention to improve the health of (Canadians), provide more effective health services and products, and strengthen the health care system

CIHR 2006

MonitorKnowledge

Use

SustainKnowledge

Use

EvaluateOutcomes

AdaptKnowledge

to Local Context

Assess Barriers/Supports to

Knowledge Use

Select, Tailor,Implement

Interventions

Identify Problem

Identify, Review,Select Knowledge

Products/

Tools

Synthesis

Knowledge Inquiry

Tailo

ring

Kno

wle

dge

KNOWLEDGE CREATION

ACTION CYCLEAPPLICATION

Graham et al 2006

Consolidated Framework for Implementation Research

Meta-theoretical and overarching typology derived from 19 theories about change / innovation / implementation

Composed of 5 domains with 39 constructs Dynamic interaction between each of the 5

domains1 Intervention characteristics: core & adaptable

periphery2 Outer setting: economic, political, social context3 Inner setting: structural, political, cultural context4 Characteristics of individuals: agency, choice & power5 Process of implementation: change process

Damschroeder et al 2009

Clinically focused KT projects

Management of

patients with

dysphagia

Oral nutrition

support for patients at

risk of malnutritio

n

Reducing the risk of hospital acquired

VTE

TK2A - approach

Focus NHS

Priorities

Partnership

working

Evidence-based

approaches

Capacity building

Focus on healthcare (NHS) prioritiesPriorities identified by health care partners - links to national policy initiatives• Quality Innovation, Productivity, Prevention,

(QIPP)• Commissioning for Quality & Innovation

(CQIN).• NICE guidelines, national guidanceLocal health priorities

• Health needs• Identified shortfalls in care• Focus on complex issues rather than quick

fixes

Partnership working

Projects embedded within the NHS

Shared ownership & responsibility for success

Focus on multi-disciplinary teams to change practiceWorking at different levels across the organisationParticipatory ways of working to achieve changeBoundary spanning and knowledge brokering roles

Evidence-based approachUtilise knowledge from implementation science

CIHR ‘Knowledge to Action’ framework to guide implementation, informed by CFIR

Evidence-based approaches to implement change, adapted to local context

Embedded evaluation

Capacity building for KT

Individuals• Knowledge translation facilitator secondments from

NHS partners• Knowledge translation research secondments from

HEI partners• PhD, post doctoral fellowships• NIHR MSc Clinical Research, ACF medicine, CATP for

nurses, AHPsClinical teams• KT skills development – evidence appraisal, change

management, evaluation etc.

Managers• KT engagement / culture – evidence informed local

policy and practice, evaluative culture

Enhancing the quality of oral nutrition support: EQONS

Aim• To enhance the quality

of oral nutrition support provided by the multi-disciplinary team to adult patients with long-term conditions through the implementation of a malnutrition screening tool (MUST+) and associated care guidelines

Objectives• To trial and evaluate two

interventions designed to facilitate the uptake of MUST+ and care guidelines• Ward-based nutrition

champions• Facilitation of the

multi-disciplinary team by a dietitian

Knowledge Inquiry

Knowledge synthesis

Knowledge tools / products

Tailoring

knowledge

Systematic reviews oral nutrition support

NICE guidanceJoanna Briggs best practiceNutrition screening toolsCare guidelinesProfessional expertise

Knowledge creation

Identify problemSelect

knowledge

Adapt knowledge to local context

Assess barriers to knowledge

use

Select, tailor implement

interventions

Monitor knowledge use

Evaluate outcomes

Sustain knowledge use

Review guidelines using AGREE

Appraise MUST Develop MUST+

Action research approach

Multi-level problem identification Understand macro, meso, micro

contextEnsure ownership of need for change at different levels of the organisation

Collect baseline data observation, audit

Survey knowledge, attitudes, barriers to ONSFeedback baseline

data to ward teams

Develop interventions andtailor to local context.Facilitate implementation of interventions in collaboration with front-line staff

Modify interventions in response to changes in local context

Repeat audit of oral nutrition support and patient recordsFeedback from facilitators, clinical staff and patient representatives via Project Advisory Group

Measure patient & staff outcomesEvaluate intervention strategies

Phased withdrawal of facilitation

Ongoing audit to monitor sustainabilityRoll out of interventions and disseminate learning

Time and tide waiteth for no man • Geoffrey Chaucer

14th Century poet

Swampy lowlands of practice rather than hard ground of theory • Donald Schon

1983

Implementation in the real world

Benefit leversPolitical and economic context

• Productivity and efficiency in climate of spending restrictions• Health organisation performance

Alignment with organisational priorities• Within and across organisation

Transformational leadership• Multiple levels: managers / practitioners• Opinion leaders, champions – expert credible sources

System change mechanisms• Shared ownership• Contextualising, Risk taking

Supporting / reinforcing structures• Standards / regulations• Communications infrastructures

Challenges

Establishing effective engagement• Symbiotic partnerships

Reconciling different agendas and time frames• Immediacy of the NHS agenda• HEI research agenda

Organisational capacity for change• lack of organisational slack

Environmental instability• Whole systems to clinical micro-systems change

Sustainability of change and scaling up

Challenges

Implementation in the real world is complex and messyWe need to be prepared to deal with unpredictability, be able to adapt and cope with complexity

Lessons learnt Understanding the context at macro, meso and micro levelThe rapidly changing context requires different ways of workingEmbedding implementation projects within the organisation • Board to bedside ownership• Identifying champions at different levels• Partnership working at all levels of the organisation(s)• Drawing upon existing systems and processes

Boundary spanners• Understanding different cultures and contexts• Speaking different languages to different audiences / stakeholders• Managing different and at times competing agendas• Operating at different levels of the organisation

• Expertise in implementation science, change management, evaluation methodologies

• Extra resources to support healthcare providers to meet objectives linked to quality, safety, effectiveness agenda

• Use evidence-based approaches to implement change adapted to the local context

• Focus on complex issues rather than quick fixes

• Participatory ways of working with on-going feedback to enhance quality

• Focus on sustainability and spread of innovation

• Positive impact on meeting NHS priorities – e.g. CQUINS, CQC, QIPP

• Sharing learning and resources across CLAHRC SY

Added value to NHS

• Collaboration with healthcare providers to support research

• Enhanced grant capture• Mechanisms to facilitate greater

impact of research• Expertise in implementation science• Capacity building

Added value to HEI

Conclusions

The CLAHRC partnership model provides a means of harnessing the capacity of higher education and the NHS to facilitate knowledge translation