From Research to Knowledge Transfer how might it actually happen in - PowerPoint PPT Presentation

From Research to Knowledge Transfer – how might it actually happen in practice? John Gabbay 22 July 2009

All aboard the bandwagon… 2

The KT/ KU/ KM industry • E.g. * “KT08” conference, Banff, Canada “propositions”: – Society expects active partnership (with KT) – Pursue KT 4 R&D or perish – Need KT “sensitivity, understanding.. & skills” throughout research – need more and better R&D on KT! – … and more training in KT – ... oh and more investment in KT – But how new is this? – Emphasis on “Mode 2” science * = Knowledge Translation 2008:http:/ / www.uofaweb.ualberta.ca/ kusp/ pdfs/ KT08% 20Framework% 20Document% 20FINAL.pdf 3

“Mode 2 science” “ Socially distributed knowledge generation:” • Knowledge developed in the context of application • Transdisciplinary (& not paradigm-bound) • Diverse situations of knowledge production • Reflexive with greater dialogue among key players • New power-sharing in QA; wider stakeholder control ( e.g. Nowotny, Scott, Gibbons. 2001, Re-thinking science: knowledge and the public in an age of uncertainty ) 4

KU08 conclusions: • LOADS more research on KT needed!! • LOADS more KT researchers needed!! • Mentors, training and incentives for KT • .. and… overcome barriers, e.g.: – Culture of target audience – Characteristics of knowledge – Insufficient capacity of KT/ disseminators – Human factors limiting receptivity – Systemic and cultural barriers – Not enough evaluation (i.e. research!) on KT… http:/ / www.uofaweb.ualberta.ca/ kusp/ pdfs/ KT08_Final_Report_Dec2008.pdf 5

Hmmmm… . 6

More down to earth - NETSCC: 7

More down to earth - NETSCC: • KT thought through as part of the research process 8

More down to earth - NETSCC: • KT thought through as part of the research process • Involving (i.e. really engaging) all key stakeholders • Importance and relevance of topic to them • Show what difference the research is going to make to them 9

Who might the stakeholders be? Providers Purchasers/ Payors Professionals Public health Physicians Policy makers P..P..P..Pretty well anyone!! Producers Politicians ( e.g. Pharmas) Public Priesthoods Press 10 Patients

NETSCC advice, in summary: • KT thought through as part of the research process • Involving (i.e. really engaging) all key stakeholders • Importance and relevance of topic to them • Show what difference the research is going to make to them • Mention all this in the application! • (NB NETSCC now m onitors Patient and Public Involvement!) 11

End of Part 1 Monographs Here come the adverts.. . ? … 12

Lots and LOTS of Monographs!! (480 and rising) Read? Hmmmm… 13

CD-ROM Searchable Up to date Comprehensive Read? Hmmmm… 14

Abstracts 15

Case Studies Spotlight Themed updates 16

Website 17

Bulletin/ email alert 18

So much for the adverts: Even simple dissemination is a struggle!! PART II - based on an ethnography of primary care that set out to explore the way clinicians actually use knowledge in day-to-day practice.. (JG and Andrée le May) 19

Design and methods • Practice: “Lawndale” – 8-partner GP practice plus 3 nurses and others – leading-edge practice – small UK rural seaside town • Ethnography: – 2 years surgeries, clinics etc; – nearly 7 years formal/ informal practice meetings – observation (participant/ non-participant) – interviews • open/ semi-structured • individual/ group/ multi-professional • informal discussions / chats • Brief “check” ethnography in an urban practice 20 • Thematic analysis

Levels of knowledge translation 4 Patient 3 Clinician 2 Local policy 1 EBP / KT / Centre 21

Level 1: (e.g. the “Evidence-based..” movement) Identify a client-centred problem Frame a focused question Search thoroughly for research derived evidence Appraise the evidence for its validity & relevance Seek and incorporate users’ views Use the evidence to help solve the problem Evaluate effectiveness against planned criteria 22

Level 2: Policy group processes 23 Gabbay, le May, Jefferson et al: Health 2003 Vol 7 283-310

Level 3: The clinician Practitioners’ “mindlines” General Individual Patient’s view 24 Gabbay, le May, BMJ 2004;329:1013

Mindlines are: – internalised collectively reinforced tacit guidelines-in-the- head that clinicians use to guide their practice – one person’s mental embodiment of their knowledge-in- practice – linked socially and organisationally to other people’s mindlines 25

Clinical world Research world Research based tacit knowledge information knowledge S ocialisation E xternalisation potential for use as “knowledge in practice” explicit tacit Other worlds Centre (eg DH) I nternalisation C ombination Patients explicit knowledge Industry SECI etc…. 26 (Nonaka & Takeuchi 1995)

The story so far: Pt 3 Clinician Identify a client-centred problem Frame a focused question 2 Local policy Search thoroughly for research derived evidence Appraise the evidence for its validity & relevance Seek and incorporate users’ views 1 EBP/ KT / Centre Use the evidence to help solve the problem Evaluate effectiveness against planned criteria 27

Another finding: multiple roles of GPs, e.g.: clinical managerial public health professional domain domain domain domain diagnosing managing resources, disease prevention keeping up to date personnel and logistics prescribing monitoring and improving screening reviewing practice quality investigating developing the IT system health promotion teaching and training advising and explaining complying with health education nurturing collegial contractual and legal networks requirements referring handling the Primary Care disease surveillance promoting general Trust practice (e.g. ’union’ work) advocating training practice staff knowing the local sustaining credibility district 28

This phase of ethnography (2005-7) • Monthly practice meetings (multi-professional) • Aimed at meeting requirements for new GP contract 29

The GP contract to implement new research-based practice in chronic kidney disease (CKD) For maximum remuneration for managing CKD: • Produce a register of all their adult patients with stages 3-5 of CKD (i.e. with an eGFR of <60ml/ min/ 1.73m2) • >90% have record of their blood pressure • >70% record blood pressure <140/ 85 • >80% of CKD registered patients with hypertension on appropriate treatment or good reason why not. 30

Transferring knowledge via QOF contractual arrangements ( a caricature ) Identify an area of suboptimal practice Commission expert review of research evidence Negotiate rigour vs pragmatism Reduce to key performance indicators Link desired change to financial incentives Make financial reward part of new contract Monitor contract against imposed criteria 31

Shall we accept the evidence and change practice? Results of routine screening Key: Key: Ensuring that we identify and register will overburden resources with all renal patients will secure QOF little or no resulting health Managerial points and ££s improvement Public health With training we can find ways within Clinical the rules to recode those with eGFR 30-60 Professional Results of routine screening will unnecessarily alarm patients Our prevalence seems comparatively low – we may be missing too many renal patients Accept all at Stage 3 We fail patients with high creatinines in ways that aren’t even mentioned in the QOF threshold It won’t be practicable to carry out all and in other guidelines (e.g. medicines the required new tests management). So let’s focus on those, not just QOF items. Ignore most at Stage 3 We need to avoid unnecessary workload – both within practice and elsewhere (e.g. the laboratory service We are already giving the right and hospital nephrologists) care to most CKD because of We will become better at managing the good follow up on their patients with renal disease related illnesses It’s generally agreed that US basis of eGFR makes it unhelpful for elderly UK populations. And low scores in But the Practice “has only Stage 3 are especially dubious. So had one death from CKD Maybe we currently fail to identify why comply? in the last 10 years!” renal patients who may therefore miss 32 out on important follow-up care

Conclusions • “Knowledge in practice” = “mindlines” • Multiple cues to amend mindlines • Little direct “knowledge translation” (SECI cycle) • Social, collective construction of mindlines • Mindlines structured, shaped, sustained by contextual demands, opportunities, constraints • Linkage between roles, goals, activities and knowledge-in-practice (missed by KT) • The roles being played influence the way the mindlines are “laid down” amended, and used • Research knowledge (even disease categories) interpreted and reconstructed by this social process Gabbay J, Le May A. In: le May A. (Ed). Com m unities of practice in health and social care 33 2009. Oxford: Blackwell.