Getting Knowledge in to Action for Healthcare Quality Kevin Rooney 12 th August 2011

1. Getting Knowledge in to Action for Healthcare Quality Kevin Rooney 12th August 2011

2. Why are you here?

3. “Quality Improvement” The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners, administrators, educators – to make changes that will lead to better patient outcome, better system performance, and better professional development. Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3

4. Who is here?

5. McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003) 439 indicators of clinical quality of care 30 acute and chronic conditions, plus prevention Medical records for 6712 patients Participants had received 54.9% of scientifically indicated care (Acute: 53.5%; Chronic: 56.1%; Preventive: 54.9%) Conclusion: The “Defect Rate” in the technical quality of American health care is approximately 45%

6. Scottish Data • 69 patients over 2 months • 47 with sever sepsis, 22 with septic shock • 26.1% were already on antibiotics prior to time 0 • 15.9% had antibiotics within 1 hour • 37.7% had antibiotics between 1 - 4 hours • 17.4% had antibiotics between 4 - 24 hours • 2.9% had received antibiotics >24 hours from time 0 Scottish Defect Rate was 58%

7. 17 years to apply 14% of research knowledge to patient care! Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70

8. “Society’s huge investment in technological innovations that only modestly improve efficacy, by consuming resources needed for improved delivery of care, may cost more lives than it saves.” “Health, economic, and moral arguments make the case for spending less on technological advances and more on improving systems for delivering care.”

9. The aspirin example • In patients who have had a stroke or TIA aspirin reduces risk by 23% • 100,000 patients – 23,000 fewer strokes • 58% of eligible patients receive aspirin = 13,340 fewer strokes

10. Two options • Fidelity – increase to 100% of eligible patients = 9,660 fewer strokes • Efficacy – requires a proportional improvement over aspirin of 74% • Clopidogrel = 10% more efficacy than aspirin

11. “Knowing is not enough; we must apply. Willing is not enough; we must do.” “The transfer of knowledge is care” Bridging the Knowledge-Practice Gap

12. Doing the right thing Clinical Decisions Doing it right Process/System Changes Quality Patient Care Transfer of Knowledge into Quality Healthcare Clinical Knowledge (Evidence Based Practice): MEDLINE, Cochrane etc Know-What Improvement Knowledge: SPSP experience, etc Know-How

13. Evidence that knowledge works • McMaster Hospitals 1990’s • “The Evidence Cart” Sackett et al JAMA 1998 • Teaching EBM skills can change practice Straus et al J Gen Intern Med 2005 • Clinical librarian services for improving patient care Scura et al JAMA 1981 • Positive impact of clinical informaticist on clinical decision making Mulvaney et al J Am Med Inform Assoc 2008

14. Our shared aim To become a world leader in healthcare quality 3 Quality Ambitions Safe, Effective, Person-Centred Care 12 Quality Outcome Indicators Care experience, Adverse events, Resource use Application of Knowledge & Quality Strategy

15. 4 Key approaches to Knowledge into Action • Knowledge or Implementation Interventions • Well defined structured items e.g. SIGN, care pathways • Relational use of knowledge • Sharing knowledge to facilitate 3 C’s • Organisational / Systems approaches • Barriers and Levers • Adapted librarian role

16. Adapted Librarian Role • Q & A service • Outreach • Q & A or Outreach plus critical appraisal • Better informed decisions • Clinical decision making • Timesaving

17. The Value of Fiona

18. Strong Knowledge Infrastructure

19. New Knowledge into Action roles • Clinical knowledge content teams – working with communities to create clinical content; package and organise as “actionable knowledge” – bundles, decision support, mobile apps etc. • Clinical librarians /informationists – expert search and training/support in clinical setting. • Outreach knowledge managers – facilitating networks for access to knowledge in community and remote settings; planned and social dissemination of knowledge including Web 2.0 etc. • Knowledge brokers – facilitating knowledge flow for quality improvement.

20. Define aims What are we trying to accomplish? What change can we make? Test, develop, implement solutions Is a change an improvement? Measure impact Aligning Knowledge Flow with Quality Improvement How do we embed the change? Spread Quality improvement processes CoP Social marketing Knowledge for action packages Assess knowledge use and evaluate outcomes Knowledge Exchange and Dissemination Knowledge Exchange and Dissemina-tion Inquiry and Knowledge Synthesis Knowledge Flow Evidence-based quality indictors Case studies After action reviews Cost-benefit analysis • Problem definition People & skill • Expert Searching directories • Capture experiential knowledge • Evidence synthesis Organise knowledge Knowledge Management activities and tools Knowledge Management Capabilities – personal & organisational

21. Clinical Content Management Knowledge Support Model Standards: metadata, taxonomy, content structure Content creation Point of Care 12 million resources ONLINE Actionable Knowledge Relevant Evidence All Literature

22. Forcing functions / Computer Reminders Effect of POC computer reminders on physician behaviour: a systematic review Shojania et al CMAJ 2010

23. Mobile Knowledge App Store Homepage

24. Pathway publication tool All Pathways View more learning (301)... View National Guideline (1) View Local Guideline (1) Quick Reference Adult Advanced Life Support Explanation Education Unresponsive? Open Airway Looks for signs of life Call 2222: Cardiac Arrest Team CPR 30:2 Until defibrillator /monitor attached 3:20 Assess rhythm Shockable VF/VT Non-shockable PEA/Asystole Feedback… Save for later Evidence more…

25. “The Scottish Patient Safety Programme is without doubt one of the most ambitious patient safety initiatives in the world – national in scale, bold in aims, and disciplined in science.  It harnesses the energies and wisdom of Scotland’s health care leaders –NHS executives, QIS experts, clinical professionals, civil servants, and more – all aligned toward a common vision, making Scotland the safest nation on earth from the viewpoint of health care.” Don Berwick, CEO and President, Institute for Healthcare Improvement

26. The application of what we know will have a bigger impact than any drug or technology likely to be introduced in the next decade.” Sir Muir Gray Director NHS National Knowledge Service & NHS Chief Knowledge Office

27. ANY QUESTIONS?