1. Translating Evidence into Practice
Sean M. Berenholtz, MD MHS FCCM
Johns Hopkins University

2. Questions: What comes to mind when you think about translating evidence into Practice? Who’s role is it at your institution to translate evidence into practice? How often do you work with the quality improvement folks? Did you receive quality care during your last doctor visit?
Survey the audience to give you a better understanding of who is present. You can ask how many people are quality, cme, administrators, etc. Create a connection so that people can understand? Pre-select 2 people to respond; having people engaged

3. Objectives:
Identify the multi-level approaches to improve translating evidence into practice
Discuss different strategies to improve patient care
Review a model for large scale knowledge translation
Identify gaps between best evidence and practice
Applying the 4Es to creating reliable health care

4. RAND Study Confirms Continued Quality Gap
10.5
Alcohol dependence
22.8
Hip fracture
40.7
Urinary tract infection
45.2
Headaches
45.4
Diabetes mellitus
48.6
Hyperlipidemia
53.0
Benign prostatic hyperplasia
53.5
Asthma
53.9
Colorectal cancer
57.2
Orthopedic conditions
57.7
Depression
64.7
Hypertension
68.0
Coronary artery disease
68.5
Low back pain
Percentage of
Recommended Care Received
Condition
Quality gap – many different; patients not getting the quality they should get; translating evidence, efficient, timely.
McGlynn et al, NEJM 2003; 348(26):

5. Approaches to Improve TRiP
Assumptions
Evidence-based medicine, Clinical practice guidelines, Decision aids
Provision of best evidence and convincing information leads to optimal decision making and optimal care
Professional education and development
Self-regulation, Recertification
Bottom-up learning based on experiences in practice and individual learning needs leads to performance change
Assessment and accountability
Feedback, Accreditation, Public reporting
Providing feedback on performance relative to peers, and public reporting of performance data motivates change in performance
Patient-centered care, Patient involvement, Shared decision making
Patient autonomy and control over disease and care processes lead to better care and outcomes
Total quality management and continuous quality improvement, Restructuring processes, Quality systems, Breakthrough projects
Improving care comes from changing the systems, not from changes in individuals
Many different models, different approaches; many multilevel approaches
Adopted from Grol R. JAMA 2001;286:

6. Grol R. JAMA 2001;286:

7. BMJ 2008;337:

8. Translating evidence into practice: A model for large scale knowledge translation
Summarize the evidence Identify local barriers to implementation Measure performance Ensure all patient receive the intervention
BMJ 2008;337:

9. Generalizable Central Line Associated Blood Stream Infection (CLABSI)
Infect Control Hosp Epidemiol 2014;35(1):56-62.
Ventilator Associated Pneumonia (VAP)
Infect Control Hosp Epid. 2011;32(4):
Venous Thromboembolism (VTE)
Arch Surg. 2012;147(10):
Colorectal Surgical Site Infections (SSI)
J Am Coll Surg. 2012;215(2):

10. Central Line Associated Blood Stream Infections
> 2 million central venous catheters placed in U.S. ICUs annually
16,000 CLABSI in U.S. ICUs annually
Mortality: 18% (0-35%)
Annual deaths: ,000
Cost per episode: $28,690-$56,000
Annual cost: $60 - $460 million
CDC. MMWR 2002; Heiselman JAMA 1994;
Dimick Arch Surg 2001

11. Gap Between Best Evidence and Practice
Knowledge
awareness or familiarity (n=77)
Attitudes
agreement (n=33)
self-efficacy (n=19)
outcome expectancy (n=8)
inertia of previous practice (n=14)
Behavior
external barriers (n=34)
Always some gap, knowledge gap, attitude or behavior
Cabana et al. JAMA 1999 11

12. Central Line Associated Blood Stream Infection (CLABSI) Prevention
Remove Unnecessary Lines
Wash Hands Prior to Procedure
Use Maximal Barrier Precautions
Clean Skin with Chlorhexidine
Avoid Femoral Lines
5 things to target

13. Standardize Care Make it easier, go to
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY

14. Creating Reliable Health Care Executive Leaders Team Leaders Staff
Engage
How Does This Make the World a Better Place?
Educate
What Do We Need to Do?
Execute
How can we do it with my resources and culture?
Evaluate
How Do We Know We Made a Difference?
Health Services Research 2006

15. CLABSI Rate for All ICUS at JHH: 1998 - Q2 2012
Crit Care Med 2004;32(10):2014

16. Michigan Keystone ICU CLABSI Rate: 2004-2012
N Engl J Med 2006;355: ;
BMJ 2010;340:c309.

17. National Efforts On the CUSP:Stop BSI Program
1,071 ICUs in 45 states
43% CLABSI reduction
Number of ICUs that achieved CLABSI rate of ZERO, more than doubled
Infect Control Hosp Epidemiol 2014 Jan;35(1):56-62.

18. Lessons Learned Harm is preventable
Many complications, including HAIs, are preventable
Should be viewed as defect
Focus on systems -- Not individuals
Far more complex than a checklist
Engage frontline staff to identify and fix local defects
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY

19. Key Concepts: Technical and Adaptive Work
Sweet
Spot
Evidence-based interventions
Local culture

20. How Will We Get There? TECHNICAL WORK ADAPTIVE WORK
Work that we know we should do, like appropriate antibiotic dosing and skin preparation
The intangible components of work, like ensuring team members speak up with concerns and hold each other accountable
Work that lends itself to standardization (e.g., checklists and protocols)
Work that shapes the attitudes, beliefs, and values of clinicians, so they consistently perform tasks the way they know they should
Evidence-based interventions
Safety culture, including teamwork

21. Learning, Development, and Capacity3
Target:
People aiming
for a career
in safety- quality work
Graduate degrees
Career development awards
Safety-quality experts
Education 2
safety-quality education
Role tailored
Target: Healthcare leaders /managers
with responsibility for improving safety-quality
- Patient Safety Certificate
Safety fellows 1
Basic safety-quality
Education
Target: All healthcare professionals
- Medical, nursing , and other healthcare professions’ students
- Residents , fellows

22. AI Patient Safety Training
Online Patient Safety Certificate
Patient Safety Fellowship
13 modules, 18 hours
6 months, didactic, mentorship
Patient Safety Certificate Program
Analytics Leadership in Patient Safety
24 modules, 5 consecutive days
12 months, didactic, mentorship
For more, visit
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY

23. Comprehensive Unit-based Safety Program (CUSP)
A practical approach to tap into the wisdom of frontline staff and improve teamwork and safety culture

24. CUSP Pre-work Comprehensive Unit-based Safety Program
Start in one unit and then spread
Imperative for frontline staff to be involved
Build strong partnerships:
Infection prevention staff
Hospital quality and safety leaders
Nurse educators
Physician leaders
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY

25. CUSP Objectives Comprehensive Unit-based Safety Program
Educate staff on science of safety
Identify defects
Partner with a senior executive
Learn from defects
Improve teamwork and communication
Jt Comm J Qual Patient Saf 2010;36:252-60
Resources:

26. Statewide Michigan CUSP ICU Results "Needs Improvement”
Needs Improvement: Less than 60% of respondents reporting good safety or teamwork climate
Statewide in % needed improvement, down to % in 2007
J Critical Care 2008;23:
Crit Care Med 2011;39(5):1-6 26

27. Best Way Forward Harm is preventable Informed by science
Many complications, including HAIs, are preventable; Should be viewed as defect
Informed by science
Technical and adaptive teamwork
Led by clinicians and supported by management
Tap into wisdom of frontline staff
Need to build capacity
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY

28. Engagement: Small group discussions from pre-work
Results from discussions with quality improvement folks at your institution
Ask:
What quality driven organizational projects are being addressed? Are there financial implications for these projects? (High level projects could be aligned with your organization’s strategic priorities, mission, vision, and external reporting requirements for quality measures.)
What quality metrics are being used?
Think about how you can CME/CPD get involved? Ask the organizational leaders is there a way they can envision how they think the CME/CPD office can get involved.