Sustainability of KT Innovations Oct 14, 2010 Knowledge Translation Canada

1. Sustainability of KT Innovations Oct 14, 2010Knowledge Translation Canada Barbara Davies RN, PhD Professor, School of Nursing Co-Director Nursing Best Practice Research Unit

2. Objectives of the session • Define sustainability and spread of innovations 2. Increase awareness of the sustainability dimension of KT models 3. Describe elements to consider when developing a sustainability action plan 4. Highlight challenges and successes experienced over 10 years of implementing nursing best practice guidelines 5. Spark the analysis of health service provision from a long-term, multi-dimensional systems perspective Nursing Best Practice Research Unit

3. What is sustainability? • “The degree to which an innovation continues to be used after initial efforts to secure adoption is completed” (Rogers, 2005) • “When new ways of working and improved outcomes become the norm” (Maher, Gustafson, & Evans, 2010)

4. The notion of “integration” ‘Not only have the process and outcome changed, but the thinking and attitudes behind them are fundamentally altered and the systems surrounding them are transformed as well. In other words the change has become an integrated or mainstream way of working rather than something ‘added on’. As a result, when you look at the process or outcome one year from now or longer, you can see that at a minimum it has not reverted to the old way of working, or old level of performance.(NHS Institute for Innovation and Improvement 2005) Nursing Best Practice Research Unit

5. The notion of “evolving” Further, it (the change) has been able to withstand challenge and variation; it has evolved alongside other changes and perhaps has continued to improve over time. Sustainability means holding the gains and evolving as required - definitely not going back’. (NHS Institute for Innovation and Improvement 2005) Nursing Best Practice Research Unit

6. Related terms* • Routinisation: When an innovation becomes entrenched into regular activities and loses distinct identity • Institutionalization: The “staying power” or relative endurance of change in an organization . The change becomes part of everyday activities or normal practices in an organization. • Re-Invention: Adapting the innovation to fit with a local situation or the degree of modification by the adopters • Spread: “The process through which new working methods developed in one setting are adopted, perhaps with appropriate modifications, in other organizational contexts *Davies, B., Edwards, N. (2009). The Action Cycle: Sustain knowledge use. In S. Strauss, J. Tetroe & I. Graham (Eds.), Knowledge Translation in Health Care: Moving from Evidence to Practice. Oxford: Wiley-Blackwell and BMJ. Nursing Best Practice Research Unit

7. Scaling Up • Addressing sustainability requires planning for “scaling up” knowledge use, including the following critical conditions: • Adequate human capacity • Supportive financial, organizational, governance, and regulatory structures • Issue of “boutique Interventions” designed for a specific setting but not feasible or applicable in a large scale due to resources or relevance (Simmons et al., 2006; Hanson et al., 2003)

8. Why is sustainability planning rarely addressed? • Only 2 of 1000 sources screened for a literature review about the diffusion of innovations in health service organisations included he term sustainability(Greenhalgh et al., 2005) • Shorter-term perspectives are the focus of health services research, possibly due to: • Limited availability of long-term funding • Different time perspectives of policy cycles across health care sectors • Disengagement of project leaders towards the end of projects

9. Sustainability is non-linear Multiple determinants interact at variable rates depending on contextual factors • receptivity to new knowledge • capacity to interpret and apply the new knowledge • individual, organization, system levels

10. Maintaining the integrity of EBP (1) Adaptation due to changes in the organization • e.g. New health care providers, changes in equipment Complex interventions, the « Hard core –soft periphery »* Labour support: Theory based aspects emotional support, comfort measures, information and advocacy Cochrane Review Hodnett et al. 2007 “all women should have support throughout labor and birth, yet evident in hospitals around the world that continuous support during labour is the exception rather than the rule” • Changes in the organization: new central fetal monitoring system *Denis et al. 2002 Health Care Management Review 27 (3) , 60-73

11. Maintaining the integrity of EBP (2) Adaptation due to the emergence of new evidence • Systems need to be put in place: • to find and appraise the results of promising new research evidence • retrieve and appraise new and updated guidelines • examine patient preferences for EBP options • obtain input about clinician’s experiences implementing guidelines • and learn about other emerging EBPs and contextual influences. Nursing Best Practice Research Unit

12. High performing Health Care organizations * • Sustainability is a challenge because their ‘just do it culture’ results in many concurrent improvement activities • This leader also highlights that there is “a continuing need to prioritize project commitments systematically, to divest those projects that produce marginal outcomes and to complete priority projects before engaging in new ones* (Baker et al. 2008, p. 260-261). Baker, G.R. (2008) High performance healthcare systems: Delivering quality by design. Toronto, Canada Longwoods Nursing Best Practice Research Unit

13. Monitoring sustainability Monitoring systems and data feedback mechanisms are needed to determine relevant process and outcome factors to assess sustainability (Pluye et al., 2004) Four Degrees of Sustainability: • Absent • Precarious • Weak • Routinization

14. Sustainability Dimension of KT models Maintain change or sustain ongoing knowledge use • 11/31 planned action theories describe a step that is separate and subsequent to evaluation* • http://www.iceberg-grebeci.ohri.ca/research/kt_theories_db.html *Graham ID, Tetroe J and the KT Theories Research Group. Some theoretical underpinnings of knowledge translation. Academic Emergency Medicine 2007; 14:936-941

15. Knowledge Creation Knowledge inquiry Knowledge synthesis Knowledge tools/ products Tailoring knowledge Knowledge to Action from: Graham et al: Lost in Knowledge Translation: Time for a Map? Monitor knowledge use Select, tailor implement interventions Evaluate outcomes Assess barriers to knowledge use Sustain knowledge use Adapt knowledge to local context Identify Problem Identify, Review Select knowledge Nursing Best Practice Research Unit http://www.jcehp.com/vol26/2601graham2006.pdf

16. NHS sustainability model:A promising developing model • Initiated as a result of sustainability being identified as a problem • Aim to identify key factors which support or hinder sustainability of improvement • Create a model that practitioners could use to assess the likelihood of sustainability • Using a Bayesian approach 250 experts identified measures, created factors and estimated the diagnostic power of the factor levels • Reported as easy to use • Model being used in England, USA, Sweden and Norway Nursing Best Practice Research Unit

17. Staff Senior leaders Process Organization Sustainability Model(NHS Institute for Innovation and Improvement, 2010) Monitoring progress Training and involvement Behaviors Adaptability Credibility of benefits Clinical leaders Benefits beyond helping patients Fit with goals and culture Nursing Best Practice Research Unit Infrastructure

18. NHS Sustainability model* • Process: Benefits beyond helping patients, credibility of evidence, adaptability of improved process, effectiveness of the system to monitor progress • Staff: Training and involvement, behaviors, senior leader engagement, clinical leader engagement • Organization: Fit with goals and the culture, infrastructure-staff equipment, policies Maher L, Gustafson D, Evans A. Sustainability Model and Guide. NHS Institute for Innovation and Improvement 2010 www.institute.nhs.uk/sustainability Nursing Best Practice Research Unit

19. The NHS sustainability model

20. Factors to consider in the development of a sustainability action plan* The same factors can both facilitate and inhibit sustainability (Wakerman et al., 2005): 1. Relevance of the topic:Is there a well-defined need and priority for the knowledge that is being implemented? Is there consensus about what knowledge needs to be sustained and what is needed to create conditions for sustainability? How does the new knowledge fit with current priorities? 2. Benefits:What are the anticipated outcomes of knowledge implementation from a biological, economic, psychological, organizational, social, political, or other perspective? How meaningful are these benefits to the various stakeholders? 3. Attitudes:What are the attitudes of the patient/ client, their family, the public, health care providers, and relevant decision-makers toward the innovation? (Buchanan et al., 2007Davies et al., 2006; Lomas; Maher et al., 2007; Nolan et al., 2005; Shediac-Rizkallah & Bone, 1998; Sibthorpe & Glasgow, 2005)

21. Factors to consider in the development of a sustainability action plan…..cont’d 4. Networks:What team or groups can be engaged to facilitate the sustainability of knowledge use? Are there people who can be engaged to cross disciplines, settings, or sectors of the health care system 5. Leadership:What actions might leaders and managers at all levels of involvement take to support the sustainability of knowledge use? Are there champions for the change? Who is responsible for continued implementation of the innovation and making modifications as new knowledge is brought forward? Who will be responsible for ensuring that relevant outcomes are met? 6. Policy articulation and integration:How will the fit between new knowledge and existing policies be assessed? How might the knowledge be integrated in relevant policies, procedures, regulatory and documentation systems?

22. Factors to consider in the development of a sustainability action plan …..cont’d 7. Financial:What funding is required to implement, sustain, and scale up knowledge? What flexibility in funding is necessary and available for reimbursement? Can cost-effective strategies be used? 8. Political:Who are thestakeholders and what power or support might be leveraged? Who will initiate scaling up processes?

23. Nursing Research (Olympics)A Canadian Team Wins the Gold Indianapolis, Indiana USA Nov 2009 Youtube   http://www.youtube.com/watch?v=k98GyW_rx5E Kirschling JM, Erickson, J.I. (2010) HEALTH POLICY AND SYSTEMS: The STTI Practice-Academe Innovative Collaboration Award: Honoring Innovation, Partnership, and Excellence

24. Best Practice Spotlight Organizations • 21 Hôpital Charles LeMoyne, Hôpital régional de Sudbury Regional Hospital, McGill University Health Centre, Niagara Health System, Royal Victoria Hospital, Saint Elizabeth Health Care University Health Network, VON Canada,  West Park Healthcare Centre, Cambridge Memorial Hospital, Chatham-Kent Health Alliance, Community Care Access Centre HNHB, Extendicare York, Hamilton Health Sciences, The Hospital for Sick Children, Hotel-Dieu Grace Hospital, London Health Sciences Centre , Niagara Region Public Health Department, The Ottawa Hospital , St. Joseph's Health Care, London, St. Joseph's Health Care, Hamilton

25. Practice Academe Innovative Collaboration AwardRNAO/BPSO/UO —Celebrating 10 years of collaboration in advancing evidence-based practice Nursing Best Practice Research Unit

26. Nursing Best Practice Clinical Guidelines: 1999-2002 Cycle 1 • Falls • Continence • Constipation • Pressure ulcers (Assessment) Cycle 2 • Healthy adolescents • Client centered care • Crisis intervention • Pain • Therapeutic relationships • Pressure ulcers (management) • Supporting families Cycle 3 • Adult asthma control • Breastfeeding • Screening for delirium, dementia and depression • Smoking cessation • Reducing foot complications for people with diabetes • Venous leg ulcers Nursing Best Practice Research Unit

27. Implementation process • Cycle 1: Common elements across cycles • Launch: Teams from all sites, presentations by guideline leaders, 2 days • Selection of site specific clinical resource nurse(s) • Developed education materials, documentation resources, policy review, general coordination • Site specific nursing and multi-disciplinary task forces • Monthly problem solving teleconferences cross guidelines • Cycle 2: Workshop on Implementation strategies • Cycle 3: Implementation Toolkit 85 (pages) Nursing Best Practice Research Unit

28. Improvement in nursing and client/patient outcomes- Short Term • All sites had statistically significant improvements • Two distinguishing implementation strategies for guideline topics with > 50% of indicators improved • Asthma, Diabetes Foot Care, Venous leg ulcers • Hands on skill practice sessions for nurses • Development of new patient education • Need for adaptation of nursing care to address recommendations to local practice Davies, B et al. (2008) Insights about the process and impact of implementing nursing guidelines BMC Health Services Research Nursing Best Practice Research Unit

29. Determinants of the sustained use of research (SURE study) • Once the initial pilot implementation funding is over, do nurses, managers and senior executives continue to implement guideline recommendations? Nancy Edwards RN PhD Jenny Ploeg RN PhD Evangeline Danseco PhD Tazim Virani RN RN PhD (c) Maureen Dobbins RN PhD Project Coordinator SURE study Cindy Versteeg RN MScN Nursing Best Practice Research Unit

30. Procedures (Multi-method Study) Interviews • Clinical resource nurses, administrators, staff Site Visits • I day, lead organization • Agenda planned in collaboration with each site • Observations of practice settings, meetings nurses, quality assurance groups, unit teams, patient volunteers Document Reviews • Policies, clinical protocols, pathways, patient education materials Nursing Best Practice Research Unit

31. Integrative Process • Synthesis by a research analyst in consultation with site visit team (PI, Research Coordinator, Clinical Expert) • Preparation of a 5-8 page executive summary report • Report reviewed and validated by key informants from the organization and revisions were made Nursing Best Practice Research Unit

32. Results Participation rate: 90% Organizations (37/41) 92% Decision-makers (112/122) 80% Nurses (77/96) 16 site visits made Average of 5 interviews per organization 21 Hospitals 10 Long-term care 6 Community care Nursing Best Practice Research Unit

33. Results Sustainability status based on meeting four of six criteria: • Current practice • Continuing education • Policies/procedures • Leadership • Workplace culture • Self-assessment on success of project and sustainability Nursing Best Practice Research Unit

34. Results Participation rate: 90% Organizations (37/41) 92% Decision-makers (112/122) 80% Nurses (77/96) 16 site visits made Average of 5 interviews per organization 21 Hospitals 10 Long-term care 6 Community care Nursing Best Practice Research Unit

35. Sustainability Status Year 2 • 43% sustained (16/37); with 69% of these as expanded (11/16) Year 3 • 59% sustained (22/37) Up to 70% organizational failure rate for new innovations Maher, L et al. 2007. NHS sustainability model Nursing Best Practice Research Unit

36. Quantitative organizational variables • Leadership • Defined as recognizable role models, leaders, champions or administrative support for continuing the implementation • the only predictor explaining 47% of the variance in how strongly the guideline permeated the organization • Not perceived utility, organizational culture for change, organizational stability, perception of educational support, organizational support for guideline implementation or perceived characteristics of the innovation Nursing Best Practice Research Unit

37. Facilitators for Sustained or Expanded Long-Term Use of Guidelines • Leadership by champions • Management support at all levels • *Ongoing staff education • *Guideline integrated into policies and procedures • Staff buy-in and ownership • *Synergy with partners and external influences • Guideline characteristics • Multidisciplinary involvement * ZERO % at non-sustained sites Nursing Best Practice Research Unit

38. Barriers for Sustained or Expanded Long-Term Use of Guidelines • Changes in staffing and structure • Lack of sustained leadership by champions • Heavy workload and limited time • Limited ongoing staff education • Lack of follow-up and feedback • Staff resistance • Limited management commitment or support • Guideline not embedded or integrated into policies, procedures or documentation Nursing Best Practice Research Unit

39. Strengths • Use of mixed methods • Large number of agencies from various sectors involved • Collaborative model engaging front-line nurses, managers, researchers • Field research Nursing Best Practice Research Unit

40. Conclusions • Implementing changes in nursing practice to be more evidence-based takes time, is dynamic, long-term and iterative process • Some organizations may take 2-3 years to show that guideline recommendations are routine part of nursing practice • Full Report: CHSRF • http://chsrf.ca/final_research/ogc/pdf/davies_final_e.pdf Nursing Best Practice Research Unit

41. Gifford, Davies, Edwards & Graham (2006). Nursing Best Practice Research Unit

42. EFFECTIVE LEADERSHIP ( Wendy Gifford et al. 2008*) LEADERSHIP FOR IMPLEMENTING GUIDELINES • Relations-Orientated • Supports • Develops • Recognizes • Change-Orientated • Influences culture • Develops vision • Implements change • Task-Orientated • Initiates structure • Monitors • Clarifies roles • Facilitates Individual Staff • Supports, encourages • Accessible, visible • Communicates well • Creates Milieu of Best Practices • Reinforces goals, vision • Influences change • Role models commitment • Shapes Structure & Process • Provides resources, policy, training, education • Monitors operations Impacts 3 levels of performance Individuals Practice Environment/ Climate Org infrastructure Manage barriers & enable guideline based care * http://www.implementationscience.com/content/3/1/51 + Outcomes Patients Staff Organization/System

43. Sustainability Challenges • Sustainability of new innovations is one of the most central and exasperating issues in addressing the gap between knowledge and practice (Mendel et al. 2008) • How and when to address the myriad of factors • Variable rates • Tension: • routinisation of one idea and receptivity to a subsequent good idea Nursing Best Practice Research Unit

44. Evidence-Informed Models of Nursing Service: Spreading Best Practices in Nursing • Research, Exchange and Impact for System Support REISS Program of Research • 22 investigators from 5 provinces • Nancy Edwards and Doris Grinspun Co-Pi’s • 5 studies Nursing Best Practice Research Unit

45. What is an Evidence-Informed Nursing Service Delivery Model? • Transforms health-services delivery • Involves primarily the work of nurses • Crosses sectors, multiple strategies, support from decision-makers at organizational, regional and system levels • Promotes rapid uptake of evidence-informed practices by practitioners and organizations • Entails focused implementation strategies within and between organizations

46. Overall Research Questions • What does it take to spread a guideline or recommendation from one or two units or organizations to a system-wide innovation that benefits all patients and providers and the health care system as a whole? • What cost drivers and increased benefits come with spreading a best practice? • What supports, sustains or gets in the way of spreading evidence-informed change?

47. Study 3: Spreading Innovation – The Best Routes to Best Practices • The Issue:Clinical practice guidelines recommend evidence-informed innovations to improve care. But administrators and healthcare providers usually need to work hard to promote use of guidelines and ensure the best treatments are available consistently across their organization. • What We Studied: • Examined naturally occurring diffusion of guidelines - how practice guidelines spread within and between organizations under normal, everyday conditions. • We created diagrams to map how innovations spread within and outside an organization, two years after implementation of an RNAO BPG. • We then visited 2 sites 7-10 years after original introduction.

50. Study 3 continued … • What We Learned: • Takes a combination of strategies: learning opportunities, champions, discussion, communicating goals • Frontline workers “deeply involved” to figure out barriers and ways around them • Strong leadership at every level to align vision, goals + activities • RNAO guidelines were sustained 7 to 10 years later • “Absolutely better” to be a patient at the hospital now than 10years earlier • Implications: • Sustaining evidence-informed innovations for the long term depends on full engagement of leaders and staff in their implementation. When people feel involved, they will see its value and benefits and stick with it in the long term.