Using Implementation Science to transform patient care (Knowledge to Action Cycle)

Collaborating for Better

Care Partnership

Master Class: ‘Using implementation science to transform patient care’

1st September 2014

International Centre for Life

@AHSN_NENC@JPresseau

Welcome and Introduction

Dr Jackie Gray

on behalf of

Ian Renwick

Chair, Collaborating for Better Care Partnership

(Chief Executive, Gateshead Health NHS Foundation Trust)

Programme09.00 Welcome

09.15 ‘Reducing variation of avoidable deaths through NIV interventions: a working case study’ Avril Lowery, Head of SafeCare, Gateshead Health NHS Foundation Trust

09.35 An overview of the ‘Knowledge to Action’ model of Implementation Science

Professor Jeremy Grimshaw

10.15 Refreshment Break

10.30 Implementation of Guidance Workshop

Workshop 1 - COPD - facilitated by Professor Jeremy Grimshaw

Workshop 2 - End of Life Care for Frail Elderly – facilitated by Dr Justin Presseau

12.00 Lunch

12.45 Implementation Workshop (Group Work and feedback)

Workshop 1 - COPD- facilitated by Professor Jeremy Grimshaw

Workshop 2 - End of Life Care for Frail Elderly – facilitated by Dr Justin Presseau

13.45 Workshop Feedback

14.15 Building organisational capacity to address clinical variation and raise standards of care

(including Q & A session)

14.45 Conclusions, Professor Jeremy Grimshaw

14.55 Next steps – action planning

15.00 Close

Reducing variation of avoidable

deaths through NIV interventions:

a working case study

Avril Lowery

Head of SafeCare,

Gateshead Health NHS Foundation Trust

Reducing variation of avoidable deaths through NIV interventions: a working case study’

Avril Lowery

Head of SafeCare

Gateshead Health NHS Foundation Trust

Background Chronic Obstructive Pulmonary Disease (COPD) is an overarching term used to

describe a number of conditions including chronic bronchitis, emphysema, chronic obstructive airways disease and chronic airflow limitation.

COPD affects 3 million people in the UK and remains the 5th most common cause of death

More than 9% of > 45year olds in Gateshead area will suffer from this condition and 25 % will die from it.

NICE Quality Standard 10 COPD Statement 11- People admitted to hospital with an exacerbation of COPD with a persistent acidotic ventilatory failure are promptly assessed for, and receive, non invasive ventilation delivered by appropriately trained staff in a dedicated setting

Prompt assessment and receipt of NIV should be defined as: assessment and receipt of NIV within 3 hours of presentation, and receipt of NIV within 1 hour of the decision being made to administer NIV.

Background Non-invasive ventilation (NIV) is a method of providing ventilatory support that

does not require the placement of an endotracheal tube. It is usually delivered via a mask that covers the nose, but occasionally a full face mask covering the nose and the mouth is required. NIV is most commonly used to treat acute respiratory failure during exacerbations of COPD

Large body of evidence illustrates that when used well, ward-based Non Invasive Ventilation has many positive outcomes :

Reduces mortality rate from AECOPD by 50% (i.e. reducing in-patient mortality from 20 to 10% and number needed to treat to save 1 life is 10 – similar to thrombolysis benefit in Acute myocardial infarction)

Reduce critical care department (CCD) admissions for respiratory failure secondary to AECOPD by 44%,

Improves survival of these patients at three months and one year, Is cost effective via preventing CCD admissions, Reduced length of stay by average 4.5 days for NIV treated patients

A need to improve delivery and timing of NIV for AECOPD across QEH

Patient pathway to NIV at QE Gateshead

Drivers for change at Gateshead NIV service set up in early 2000’s and unchanged since 1,115 patients/year admitted with AECOPD. 71 patients/year receive NIV for AECOPD National audit data would suggest that we should expect to treat

290 patients/year with NIV. Missing up to 19 patients/ month due to bed pressures &

requirement for NIV not being recognised in all appropriate patients

Limited to being delivered on respiratory ward or CCD Provision for only 3 patients at any one time Rarely beds immediately available on respiratory ward Sub-optimal initial treatment Delay in commencement of NIV Staffing – relied on ward nursing staff -24 beds

Drivers for Change Poor outcomes compared to national audit results:

Mortality - for all NIV patients 40% in 2012 (31% nationally)

Readmissions - e.g. 1 of the 4 patients who potentially could have benefited from NIV in one month readmitted within 30 days of discharge

LOS - patients treated on CCD have delays in transfer to respiratory ward for ongoing care – slows discharge home

Failure to meet target of NIV within 1 hour of failed maximal medical therapy

• time to NIV for A&E admissions 5 hours

• Time to NIV for patients admitted to CCD from A&E median of 2.5 hours

What did we do ? Weekly multidisciplinary ward base case review well

established - Hogan and NCEPOD outcome scores introduced more recently

Presentation of cases and key learning at M&M steering group – supported business case for development of NIV service

Funding for 4 new IV machines (£300,000)

4.8 WTE band 6 specialist nurses to provide 24/7 NIV nurse led service (£300,000)

Further non- recurrent funding £15,000 ( training & education etc.)

Some minor structural changes

Anticipated benefits of new nurse led service

Early involvement in AECOPD across whole TrustOptimisation of treatment ( preventing oxygen toxicity)Early arterial blood gases Commencement of NIV in A&E and any ward areaPrompt transfer to respiratory ward for ongoing care Identification of patients who may benefit from critical

care involvementContinued support and follow up for patients

established on NIV Education and teaching throughout Trust Potential reduced LOS = cost savings Timely, safe, streamlined patient pathway

Early results

Early evidence that the service is working well for patients and meeting national standards

Service is now seeing and assessing 100 patients per month An average of 15 patients per month starting treatment with Non-

Invasive Ventilation - double the number of patients previously. This is being achieved within one hour in 100% of patients in line

with BTS guideline recommendations. Our data indicates that NIV is successful in 76% of patients, an

improvement on 66% in 2012. Our COPD patients treated with NIV now match trial mortality rates

(10% in-patient mortality) and all cause in-patient mortality matches other large cohorts within the literature (33%, previously being 40% in 2012).

Key enablers

Trust commitment to high quality care

Development of the Trust Morality and Morbidity governance framework

Leadership and clinical ‘buy in’

Learning from multidisciplinary case reviews

Key challenges

Funding

Staffing

Clinical expertise and availability

Some resistance from non clinical to set up costs

The Future…

Expansion of service

Growth of team

Protected NIV beds

Widen patient criteria

Education &

Awareness

The future for improvement

Continue to develop and embed multidisciplinary review of deaths

Ensure key learning is shared and developed into action to improve patient care and pathways

Continue to develop systems for meaningful data collection to provide assurance on the quality of the care we provide our patients/ identify deficits in service provision including the patient & staff perspectives

Encourage collective efforts and team working to enable effective and sustainable change

‘Knowledge to Action’ model

of Implementation ScienceReducing clinical variation

Raising standards of care

Professor Jeremy GrimshawSenior Scientist, Ottawa Hospital Research Institute

Professor, Department of Medicine, University of Ottawa

Canada Research Chair in Health Knowledge Transfer and Uptake

Background

• Consistent evidence of failure to implement evidence based recommendations 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 evidence based recommendations is fundamental challenge for healthcare systems to optimise care, outcomes and costs

Schuster, McGlynn, Brook (1998). Milbank Memorial Quarterly

Grol R (2001). Med Care

Approaches to implementation

ISLAGIATT

principle

Martin P Eccles

‘It Seemed

Like A Good

Idea At The

Time’

Implementation science

• Implementation is a human enterprise that can be studied to understand and improve knowledge translation approaches

• Implementation science is the scientific study of the determinants, processes and outcomes of knowledge translation.

• Goal is to develop a generalisable empirical and theoretical basis to optimise implementation activities

Developing implementation science in the Academic Health

Science Network

Developing implementation

science in the Academic Health

Science Network• To facilitate participants’ use of implementation

science theory & tools to address clinical variation and raise standards of care

• To enable participants to explore their organisational capability with respect to the skills, knowledge, and resources required to address clinical variation and raise standards of care

Knowledge to Action Cycle

Knowledge to

action

Graham et al

(2006). Lost in

Knowledge

Translation. Time

for a Map? Journal

of Continuing

Education for

Health

Professionals

Knowledge to Action Cycle

Knowledge to action cycle

Knowledge to

Action loopFrom: Graham ID et al.

Lost in Knowledge

Translation: Time for a

Map? Journal of

Continuing Education in

the Health Professions,

2006

Knowledge creation funnel

Knowledge creation funnel


Knowledge to Action loopFrom: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006



Specifying behaviours of interest

• What is the behavior (or series of linked behaviors) that you are trying to change?

• Who performs the behavior(s)? (potential adopter)

• When and where does the potential adopter perform the behavior?

• Are there obvious practical barriers to performing the behavior?

• Is the behavior usually performed in stressful circumstances? (potential for acts of omission)

Specifying behaviours of interest

• Often useful to specify target behaviours in terms of:

– Action being performed

– Target at which the action is directed

– Context in which action is performed

– Time during which the action is performed.



Adapting knowledge to local

context

• May require additional data collection to assess applicability of knowledge to local context

• May require modification of recommended actions based upon applicability, resources and contextual issues



Designing

interventions

Designing interventions

Who needs to do what differently?

Using a theoretical framework, which barriers and enablers need to be addressed?

Which intervention components could overcome the modifiable barriers and enhance the enablers?

How will we measurebehaviour change?








Assessing barriers to implementation

• Formal assessment of context, likely barriers to implementation

• Mixed methods

– Literature review

– Informal consultation

– Focus groups

– Surveys

• Needs interdisciplinary perspective

Barriers to implementation

• Structural (e.g. financial disincentives)

• Organisational (e.g. inappropriate skill mix, lack of facilities or equipment)

• Peer group (e.g. local standards of care not in line with desired practice)

• Individual (e.g. knowledge, attitudes, skills)

• Professional - patient interaction (e.g. problems with information processing)

Theoretical

Domains

framework

Theoretical Domains Framework

Cane 2012

• Knowledge

• Skills

• Social/professional role

and identity

• Beliefs about capabilities

• Optimism

• Beliefs about consequences

• Reinforcement

• Intentions

• Goals

• Memory, attention and decision processes

• Environmental context and resources

• Social influences

• Emotion

• Behavioural regulation

Behaviour Change Wheel

Behaviour Change Wheel

Ability• Physical • Psychological

Conscious and automatic decision processes

Environmental factors • Physical• Social










• Scheduled consequences• Reward and threat• Repetition and substitution• Antecedents• Associations• Covert learning• Natural consequences

• Health consequences• Feedback and monitoring• Goals and planning• Social support• Comparison of behaviour• Self belief• Comparison of outcomes• Identity• Shaping knowledge• Regulation



• Graded tasks - Set easy tasks, and increase difficulty until target behavior is performed.

• Behaviouralrehearsal/practice - Prompt the person to rehearse and repeat the behavior or preparatory behaviors



Behaviour Change Techniques

Modes of Delivery

Theory / Mediators


Usability studies• Develop prototype intervention• Test prototype in 5 to 8 subjects to review content and

format using ‘think aloud’ methodology. These sessions will be audio recorded and the results transcribed and analysed.

• In general a modest number of subjects are required for usability testing (e.g. 8-9 subjects), and often 4 to 5 are necessary to identify 80% of the usability problems.

• Cycles of design, development and testing will be completed until no further major revisions are needed.



Implementation of Guidance

Workshops:

Workshop 1 COPD – facilitated by Prof Jeremy Grimshaw

Workshop 2 End of Life Care for Frail Elderly –facilitated by Dr Justin Presseau

Workshop Feedback

Building organisational capacity

to address clinical variation and

raise standards of care

(including Q & A session)

Conclusions

Professor Jeremy Grimshaw

Next steps – action planning/

future Master Class

Promoting use of implementation

science beyond this session

How many of you are motivated to

use the tools we used today in

your own setting?

Motivation is rarely enough to

ensure change

Two simple but remarkably

effective strategies

• Clearly, concrete description of when, where, and how you will perform an action

• Anticipated barriers to you performing that action, and realistic solutions to circumvent the barrier

• Demonstrated to help promote good intentions being translated into action

Taking today’s insights forward into your

organisation: when, where & how

• Step 1: choose and write an action that you want to take in your organisation to apply what we have covered today.

• Step 2: Write:– When you will do it (be specific)

– Where you will do it (be specific)

– How you will do it (be specific)

• 3 mins

The best laid plans…

• Now, imagine yourself enacting that when, when and how plan.

• Can you envisage anything preventing you from doing it?

• How would you feasibly address that barrier?

• Write:– IF barrier __________________________ occurs– THEN I WILL ________________________ to ensure I

can enact my plan

Closing remarks

Dr Jackie Gray

NEQOS

Get involved in the Work

Programme

• Sign up at the registration desk (in main foyer)

or

• Email Dr Jackie Gray [email protected]

mailto:[email protected]

Keep up to date with developments:• Sign up for the e- bulletin at the registration desk

(if you haven’t already)

Resources will be available on:

You Tube - video will be uploaded (a link included in next e- bulletin)

Slide Share - slide deck will be uploaded (link included in next e-bulletin)

AHSN web site www.ahsn-nenc.org.uk

NEQOS web site www.neqos.nhs.uk/

Twitter - @AHSN_NENC

http://www.ahsn-nenc.org.uk/

http://www.neqos.nhs.uk/

Additional materials from the

workshop sessions

WORKSHOP 1: COPD IMPLEMENTATION SCENARIO

WORKSHOP 1: COPD IMPLEMENTATION SCENARIO

Thank you

Healthcare

Using Implementation Science to transform patient care (Knowledge to Action Cycle)