CLAHRC for South Yorkshire Collaboration for Leadership in Applied Health Research and Care for South Yorkshire (CLAHRC SY). Translation of Knowledge into Better Quality Care Learning from the NIHR CLAHRC for South Yorkshire Kate Gerrish & Andrew Booth

CLAHRC for South Yorkshire Outline Kate Gerrish Overview of the CLAHRC initiative Kate Gerrish Translating knowledge into action: an example Andrew Booth Knowledge into action: everybody’s business!

CLAHRC for South Yorkshire NIHR Collaboration for Leadership in Applied Health Research and Care for South Yorkshire (CLAHRC) NIHR programme of applied research, and implementation of research focusing on self management of long-term conditions COPD, diabetes, obesity, stroke, genetics, chronic depression, health inequalities, telehealth Collaboration between universities, NHS commissioners and healthcare providers Building capacity to undertake research and implementation £20 million over 5 years ( ) £10m from NIHR with matched funding from partners Barnsley Doncaster Rotherham Sheffield

CLAHRC for South Yorkshire Translating knowledge into action To achieve improvements in the quality of patient care and service delivery through developing step change in the implementation of research evidence into healthcare practice Aim

CLAHRC for South Yorkshire Principles Priorities identified by NHS partners. NICE guidelines, national guidance etc. Focus on NHS clinical priorities for which there is an evidence-base Projects embedded within the NHS Shared ownership Focus on multi-disciplinary teams to change practice Partnership working to facilitate KT Use KT frameworks to guide implementation Evidence-based strategies to implement change Embedded evaluation & feedback Use evidence-based strategies to achieve change Knowledge translation facilitator secondments from NHS partners Knowledge translation research secondments from HEI partners Capacity building

CLAHRC for South Yorkshire Knowledge translation Closing the gap between what we know and what we do Making users (practitioners, managers, patients) aware of knowledge / innovations and facilitating their use of it to improve patient care and care delivery

CLAHRC for South Yorkshire 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 Canadian Institutes for Health Research

CLAHRC for South Yorkshire Clinically focused KT projects Management of patients with dysphagia Oral nutrition support for patients at risk of malnutrition Reducing the risk of hospital acquired VTE

CLAHRC for South Yorkshire KT projects focused on service delivery Trialling and evaluating an organisational approach to quality improvement through the implementation of a Microsystems Coaching Academy Evaluating the application of clinical microsystems methodology to redesigning a community falls service Promoting patient safety through cross boundary working to promote medicines re- ablement

CLAHRC for South Yorkshire KT projects focused on theory development Tinkering and tailoring: understanding the trajectory of complex innovations in healthcare setting Exploring scale- up, spread and sustainability: tracing a health care innovation about dysphagia KT casebook: capturing learning from KT initiatives

CLAHRC for South Yorkshire Collaboration for Leadership in Applied Health Research and Care for South Yorkshire (CLAHRC SY). Translating knowledge into action Implementing evidence on the prevention of hospital acquired venous thrombo-embolism

CLAHRC for South Yorkshire Aims Patients risk assessed on admission and 24 hours later Patients at risk prescribed appropriate prophylaxis in accordance with NICE guidance Patients provided with anti-embolism stockings have them fitted and monitored in accordance with NICE guidance Patients/carers offered information (written & verbal) on VTE prevention as part of admission and discharge process To reduce the risk of hospital acquired VTE by ensuring

Approach Medical wards in one within an English NHS Foundation Trust Setting Action research approach using Knowledge to Action cycle (Graham et al 2006) Approach Facilitation using best practice champion model Education intervention Audit and feedback, Root cause analysis Implementation strategies observation, interviews, questionnaires feedback interim data to evaluation wards Data collection methods

Monitor Knowledge Use Sustain Knowledge Use Evaluate Outcomes Adapt Knowledge to Local Context Assess Barriers/ Supports to Knowledge Use Select, Tailor, Implement Interventions Identify Problem Identify, Review, Select Knowledge Products/ Tools Synthesis Knowledge Inquiry Tailoring Knowledge KNOWLEDGE CREATION ACTION CYCLE APPLICATION Knowledge to Action Graham et al 2006

CLAHRC for South Yorkshire Knowledge Inquiry Knowledge synthesis Knowledge tools / products Tailoring knowledge Systematic reviews risk assessment & prevention of VTE Exemplar sites NICE guidance NICE Quality Standards Risk assessment tools Patient information Knowledge creation Primary research

Identify problem Select 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 Develop local policy Appraise national screening tool, patient information Action research approach Multi-level problem identification Understand macro, meso, micro context Ensure ownership of need for change at different levels of the organisation Collect baseline data observation, audit Survey knowledge, risk assessment / prevention VTE Feedback baseline data to ward teams Develop interventions and tailor to local context. Facilitate implementation of interventions in collaboration with front-line staff Modify interventions in response to changes in local context Repeat baseline data collection Feedback from best practice champion, clinical staff and patient representatives via Project Steering Group Measure patient & staff outcomes Evaluate intervention / implementation strategies Phased withdrawal of facilitati on Ongoing audit to monitor sustainability Roll out of interventions and disseminate learning

CLAHRC for South Yorkshire Knowledge was limited but has improved Medication knowledge was good, then decreased when medication changed, now improved again Prevention was not seen as a clinical priority but this is changing Knowledge & attitudes Patients received prophylaxis & still developed VTE Estimation that 50% of people develop VTE in the community Root cause analysis Initially risk assessment compliance was poor & prescribing of chemical prophylaxis was good Risk assessment has improved significantly to attain CQUIN / patient safety targets Other aspects that are improving are provision of patient information, prescribing / management of anti embolic stockings Compliance Outcomes

CLAHRC for South Yorkshire Challenges Board to bedside – importance of strategic and clinical leadership Establishing effective engagement Immediacy of NHS agenda Reconciling different agendas and time frames Lack of organisational slack in the NHS Organisational capacity for change Whole systems to clinical micro-systems change Dealing with unpredictabilitySustainability of change

CLAHRC for South Yorkshire Collaboration for Leadership in Applied Health Research and Care for South Yorkshire (CLAHRC SY). Knowledge Into Action: Everybody’s Business! Andrew Booth

CLAHRC for South Yorkshire Take Home Points Information Evidence Knowledge & Know How Not “knowledge brokers” but “knowledge broking roles” Global “Local” Localised “Patch” Knowledge throughout Action New skills/knowledge build on existing strengths

The Knowledge Supply Chain Information Evidence Knowledge

The Knowledge Supply Chain Information Evidence Knowledge Brokerage roles Increasing Importance of Context

CLAHRC for South Yorkshire Q. Who are the Knowledge Brokers? Strategic Brokering of Priorities and Actions (NHS/CLAHRC/University) Facilitators (CLAHRC/NHS/University) Local leads (NHS/CLAHRC) Local academics (University/CLAHRC) National/International academics (Universities) A…..We All Are! (i.e. Knowledge Broker is a role not a job description! Main variables are type of knowledge, context and intensity of involvement)

CLAHRC for South Yorkshire “Our experience with the Knowledge to Action theme of the National Institute for Health Research-funded South Yorkshire Collaboration for Leadership in Applied Health Research and Care (CLAHRC) suggests that the knowledge broker position is not a single role but rather comprises a complex network of complementary roles”. Booth A. Bridging the 'Know-do gap': a role for health information professionals? Health Info Libr J. 2011; 28(4):331-4.

CLAHRC for South Yorkshire What is the Knowledge? RoleKnowledge StrategicNational/Local Priorities; Local Context; KT methods FacilitatorsThe Health Service; Facilitation Local Leads“Patch” knowledge; clinical expertise Local AcademicsLocal context; KT methods National/ International Academics* Models, Techniques and Examples * e.g. Professor Huw Davies; Professor Ian Graham

CLAHRC for South Yorkshire Some Examples RoleExample Strategic What are the Must-Dos? Locally? Nationally? Who do we need to influence? Facilitators What is After Action Review? How has it been used in the NHS? Local Leads Which wards can we work with? Who are their Opinion Leaders? Who do I need to speak to? Local Academics What is Implementation Fidelity? Why is it Important? How do you collect, organise and share Good Practice? National/ International Academics How useful is the Canadian Institutes of Health Research model of knowledge translation? What are the advantages of the Knowledge to Action framework?

CLAHRC for South Yorkshire Achievements RoleExample Strategic Organisational relevance/support Facilitators Judicious Selection of Methods. Successful Change projects. Organisational Learning. Local Leads Local relevance/support/capacity Local Academics Tools, Individual and Team Training & Development; Structure for KT Workbook National/ International Academics Organisational Training & Development; Capacity Building

CLAHRC for South Yorkshire 150 Google Scholar Citations

CLAHRC for South Yorkshire

CLAHRC for South Yorkshire Knowledge Throughout Action e.g. patient safety in community medicine management Evidence Search and Synthesis (Initiation) e.g. After Action Review Identification of Good Practice (Consolidation & Review) e.g. Sustainability and Spread Identification of Models/Theories (Evaluation) e.g. KT Workbook Identification of Good Practice (Dissemination)

CLAHRC for South Yorkshire Building on Existing Skills Searching (Literature and Good Practice) Synthesis (Scoping/Mapping etc) Facilitation (cp. Evidence Based Practice) Development of Tools/Checklists etc. Dissemination Products and Mechanisms BUT ALSO Local Knowledge Knowledge of the NHS

CLAHRC for South Yorkshire A Brief Note on Sources e.g. King’s Fund Library e.g. SHSC Health Management Library and Information Service Good Practice e.g. KT Clearing House e.g. Canadian Foundation for Healthcare Improvement e.g. Implementation Science Knowledge Translation

CLAHRC for South Yorkshire Take Home Points - Recap Information Evidence Knowledge & Know How Not “knowledge brokers” but “knowledge brokering roles ” Global “Local” Localised “Patch ” New skills/knowledge built on existing strengths

CLAHRC for South Yorkshire “The value of a team approach comes not simply from the cumulation of skills, knowledge and expertise. Arguably an even more important outcome comes from the broadening of perspective offered by different disciplinary backgrounds and interests”. Booth A. Bridging the 'Know-do gap': a role for health information professionals? Health Info Libr J. 2011; 28(4):331-4.

CLAHRC for South Yorkshire Conclusions Challenges / barriers to knowledge translation Techniques and tools Leadership and collaboration Knowledge brokering Enablers

CLAHRC for South Yorkshire Conclusions Implementation in the real world is complex and messy We need to be able to deal with unpredictability, be able to adapt and cope with complexity Knowledge brokering, leadership and collaboration, tools and techniques help handle this complexity

CLAHRC for South Yorkshire Collaboration for Leadership in Applied Health Research and Care for South Yorkshire (CLAHRC SY). Contacts Kate Gerrish: Andrew Booth: This presentation presents independent research by the Collaboration for Leadership in Applied Health Research and Care for South Yorkshire (NIHR CLAHRC SY). The views and opinions expressed are those of the authors, and not necessarily those of the NHS, the NIHR or the Department of Health. CLAHRC SY would also like to acknowledge the participation and resources of our partner organisations. Further details can be found at