The Knowledge To Action (K2A) Cycle: Providing a Framework for Implementation

1. The Knowledge To Action (K2A) Cycle:Providing a Framework for Implementation Ian Graham, PhD, FCAHS August 6, 2014 TEACH, NYAM

2. Session objectives Learn about the K2A Cycle (see Chapter 3.7a, p.249) Be able to identify and discriminate action phases of the K2A cycle

3. Disclosures/context • Knowledge Translation in Healthcare (2009, 2nd edition 2013, co-editor) (do not receive royalties) • Evaluating the Impact of Implementing Evidence-based Practice (2010, co-editor). • Co-originator: • Ottawa Model of Research Use (OMRU) • Practice Guideline Evaluation and Adaptation Cycle (PGEAC) • Can-Implement • ADAPTE process • Knowledge to Action (K2A) Cycle • Queens University Roadmap for Knowledge Implementation (QuRKI) • Founding member • International ADAPTE Collaboration • No relationships with the bio-pharma industry

4. So what is knowledge translation?

5. It’s all in the name Knowledge to action (KTA) Knowledge Transfer (KT) Knowledge Translation (KT) Research Use/Utilization Knowledge Exchange (KE) Knowledge mobilization Implementation

6. So what is KT? It comprises: the practice of knowledge translation/implementation: Closing the gap between what we know and what we do (the reducing the know-do gap) Making users aware of knowledge and facilitating their use of it to improve health and health care systems Transforming evidence into practice (moving knowledge into action) & Research/science: KT science/implementation science (studying the determinants of knowledge use and effective methods of promoting the uptake of knowledge) doing research in a collaborative fashion (iKT)

7. Just a bit of theory

8. Does anyone suffer from TAS? or FAS? Warning signs and symptoms Eye rolling Sighing Involuntary utterances OMG HML JKMN Hyperventilating Fainting Affects people of all ages More common in men and physicians

9. TAS? FAS ? Theory Averse Syndrome Framework Averse Syndrome

10. Types of models/theories of change Change theories/models fall into two basic kinds Classical - models that describe change, but were not specifically designed to cause change (normative) Planned – models that are intended to be used to guide or cause change refer to deliberately engineering change that occurs in groups that vary in size and setting. those who use planned change theories/models may work with individuals, but their objective is to alter ways of doing things in social systems. help change agents control variables that increase or decrease the likelihood of the occurrence of change.

11. K2A Cycle Framework: A Planned Action Model • based on a concept analysis of 31 planned action theories • was developed to help make sense of the black box known as ‘knowledge translation’ or ‘implementation’ • offers a holistic view of the phenomenon by integrating the concepts of knowledge creation and application or action Graham ID et al. Lost in knowledge translation: time for a map. JCEPH 2006, (1):13-24

12. The K2A framework The framework takes a systems perspective: knowledge producers and users are situated within a social system or systems that are responsive and adaptive, although not always in predictable ways. the K2A process is considered iterative, dynamic, and complex, with the boundaries between the knowledge creation and action components are fluid and permeable.

13. The K2A framework falls within the social constructivist paradigm which privileges social interaction and adaptation of research/evidence and takes local evidence, context and culture into account designed to be used by a broad range of audiences

14. Monitor Knowledge Use Select, Tailor, Implement Interventions Evaluate Outcomes Assess Barriers/ Supports to Knowledge Use Sustain Knowledge Use Start here Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge Application cycle

15. Knowledge Inquiry Tailoring Knowledge Synthesis Products/ Tools KNOWLEDGE CREATION

16. Knowledge Inquiry Tailoring Knowledge Synthesis Products/ Tools Monitor Knowledge Use Select, Tailor, Implement Interventions Evaluate Outcomes KNOWLEDGE CREATION Assess Barriers/ Supports to Knowledge Use Sustain Knowledge Use Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge

17. The 2013 version of the K2A Cycle

18. Alternateways of using the K2A Cycle “push” research “pull” research “linkage and exchange” (or integrated Knowledge Translation)

19. Identify Problem Identify, Review, Select Knowledge Monitor Knowledge Use Select, Tailor, Implement Interventions Tailoring Knowledge Evaluate Outcomes Assess Barriers to Knowledge Use Sustain Knowledge Use Adapt Knowledge to Local Context Products/ Tools Synthesis Knowledge Inquiry KNOWLEDGE CREATION Push: Researchers, push research/syntheses/guidelines to knowledge-users Push

20. Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Products/ Tools Synthesis Knowledge Inquiry KNOWLEDGE CREATION Pull: Knowledge-users pull research/syntheses/guidelines that they need for their practice/policy decisions Pull Monitor Knowledge Use Select, Tailor, Implement Interventions Evaluate Outcomes Assess Barriers to Knowledge Use Sustain Knowledge Use Adapt Knowledge to Local Context

21. KNOWLEDGE CREATION Knowledge Inquiry Synthesis Products/ Tools Identify Problem Identify, Review, Select Knowledge Monitor Knowledge Use Select, Tailor, Implement Interventions Tailoring Knowledge Evaluate Outcomes Assess Barriers to Knowledge Use Sustain Knowledge Use Adapt Knowledge to Local Context iKT: Researchers and knowledge-users work together to define and refine research questions and to put it into practice Integrated Knowledge Translation

22. K2A Cycle: an illustration Community care of venous leg ulcers Collaborative interdisciplinary approach Co-PI Dr. Margaret Harrison, Queen’s University 8 year program of research and implementation A community-researcher alliance to improve chronic wound care CIHR KT Casebook, (Graham et al, 2006) http://www.cihr-irsc.gc.ca/e/30669.html

23. Pick the targeted issue carefully “ To result in an action, the knowledge being translated needs to be relevant, appropriate, applicable, timely and reasonable to the needs of the intended users” *Campbell B. Applying knowledge to generate action: A community-based knowledge translation framework. JCEHP 30(1):65-71, 2010

24. Venous Leg Ulcers Population with Leg Ulcers in particular: Common, costly, complex Chronic, recurring Debilitating, isolating condition 80% care reported to be community-based

25. A Picture is Worth a 1,000 Words

26. KNOWLEDGE CREATION Knowledge Inquiry Synthesis Products/ Tools Identify Problem Identify, Review, Select Knowledge Monitor Knowledge Use Select, Tailor, Implement Interventions Tailoring Knowledge Evaluate Outcomes Assess Barriers to Knowledge Use Sustain Knowledge Use Adapt Knowledge to Local Context iKT iKT approach to project

27. Knowledge Inquiry Tailoring Knowledge Synthesis Products/ Tools Use of external and local evidence woven throughout all phases of the project KNOWLEDGE CREATION

28. EITHER Start with problem/issue concern and look for research to solve the problem What is the magnitude of the problem? How do you know? Are all the relevant stakeholders involved in determining the problem? Monitor Knowledge Use KNOWLEDGE CREATION Knowledge Inquiry Synthesis Products/ Tools Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Identify Problem Identify, Review, Select Knowledge Select, Tailor, Implement Interventions Evaluate Outcomes Assess supports/ Barriers to Knowledge Use Sustain Knowledge Use Adapt Knowledge to Local Context

29. OR Become aware of current research/systematic review/guideline and assess whether current practice is in keeping with it How to determine if and what knowledge How to determine if and what knowledge is needed? from an individual, team, unit and systems perspective Does the evidence address an issue of relevance to the end user? Is it high quality evidence? If using a guideline, does it adhere to the AGREE and IOM quality criteria? Monitor Knowledge Use KNOWLEDGE CREATION Knowledge Inquiry Synthesis Products/ Tools Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Identify Problem Identify, Review, Select Knowledge Select, Tailor, Implement Interventions Evaluate Outcomes Assess supports/ Barriers to Knowledge Use Sustain Knowledge Use Adapt Knowledge to Local Context

30. Example Homecare authority identified wounds as issue (growing supply budget) and engaged researchers Issue clarification requires local evidence to provide baseline and planning info at regional level Population prevalence and profile studies Knowledge, attitudes, practice (KAP surveys of providers) Environmental scan of expenditures Gap analysis of current vs best practice Monitor Knowledge Use Identify Problem Identify, Review, Select Knowledge Identify Problem Identify, Review, Select Knowledge Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate Outcomes Knowledge Inquiry Tailoring Knowledge Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context

31. Knowledge inquiry Knowledge Inquiry Tailoring Knowledge • Example: • Regional prevalence study: • 2 phased approach: • 1- case finding • 2- detailed clinical assessments • In homecare- admin database (supplies) • Surveys of: • family physicians • podiatrists • LTC facilities • Advertisements in 15 local and community papers for self-referral • 531 individuals identified with active LU, estimated 836 for region • Harrison MB, Graham ID, Friedberg E, Lorimer K, Vandelvelde-Coke S. Assessing the population with leg and foot ulcers. CN 1001, 97 (2): 18-23 Synthesis Products/ Tools

32. Knowledge inquiry Knowledge Inquiry Tailoring Knowledge Synthesis Profile studies: - 107 confirmed VLU cases from prevalence study Phase II (clinical assessment) • Sociodemographic characteristics • Circumstances of living • Health history • Leg ulcer history • Health care providers seen • 66 clients receiving care in 1 month at 1 agency (chart audit) • Audit tool based on recommendations from 3 practice guidelines Lorimer K, Harrison MB, Graham ID, Friedberg E. Venous leg ulcer care: How evidence-based is nursing practice? Wound Care 2003:30:132-42 Lorimer K, Harrison MB, Graham ID, Friedberg E. Assessing venous ulcer population characteristics and practice in a home care community. OstomyWound Management. 2003:49(5):32-43 Products/ Tools

33. Knowledge inquiry Knowledge Inquiry Tailoring Knowledge Synthesis Products/ Tools Knowledge Attitudes, Practice (KAP) surveys: • faxback survey of 425 family physicians in Ottawa-Carleton, 214 returned questionnaires (61% response rate) • all visiting nurses at 3 nursing agencies (n=170), paper based survey with return envelop and $1 scratch lottery ticket, 124 surveys returned (73% response rate). Graham ID, Harrison MB, Shafey M, Keast D. Knowledge and attitudes regarding care of leg ulcers. Canadian Family Physician, 2003 49:896-902 Graham ID, Harrison MB, Moffat C, Franks P. :eg ucler care: nursing attitudes and knowledge. Canadian Nurse 2001 97(3):19-24.

34. Knowledge inquiry Knowledge Inquiry Tailoring Knowledge Synthesis Products/ Tools Expenditure review: • Descriptive survey conducted over 4 week period • 192 clients • 2270 care visits • mean treatment time 26 min, • mean travel time 17 min • $80.62 (supplies $21.06) per visit • cost per client $397 (SD =381) • 6% of homecare clients consuming 20% of supply budget • Estimate: 192 clients costing 1.3M per year Friedberg E, Harrison M, Graham ID.. Current home care expenditures for persons with leg ulcers. Wound Care 2002, 29:186-92

35. The local evidence Regional prevalence & profile study Prevalence: 1.8/1000 population (> 25 years) 3/4 were > 65 years Majority independently mobile 60% had 4 or more co-morbid conditions Recurrent - 64% had a recurrent venous ulcer Longstanding - 60% had ulcer > 6 months, 1/3 >1 year 40% had 2 or more ulcers Environmental scan, expenditures Average 19 different nurses saw any one client in month 40% received daily or twice a day visits 4 week costing estimated 192 cases $1.26 million nursing & supply expenditures (Harrison, et al 2001; Lorimer, et al 2003; Nemeth, et al 2003, 2004; Friedberg, et al 2002)

36. What should be best practice for (VLU management)? Review of published (Pubmed) and grey literature (accessible via the internet) to identify: Evidence on assessment and management of venous leg ulcers high level evidence from numerous RCTs, Cochrane Systematic Review numerous international Clinical Practice Guidelines available of variable quality (appraised using AGREE instrument) Monitor Knowledge Use Identify Problem Identify, Review, Select Knowledge Identify Problem Identify, Review, Select Knowledge Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate Outcomes Knowledge Inquiry Tailoring Knowledge Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context

37. Gap analysis of best practice vs current practice (Know do Gap) Monitor Knowledge Use Identify Problem Identify, Review, Select Knowledge Identify Problem Identify, Review, Select Knowledge Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate Outcomes Knowledge Inquiry Tailoring Knowledge Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context

38. Monitor Knowledge Use Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate outcomes Knowledge Inquiry Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Adapt Knowledge to Local Context Adapt/contextualize knowledge to be implemented to context Example Practice Guidelines Evaluation and Adaptation Cycle (Graham et al 1999; Graham et al 2005)

39. The adapted protocol

40. What might be the individual (patient or provider), organizational and team barriers to uptake of best practice? What might be the individual, organizational and team supports to uptake of best practice? Monitor Knowledge Use Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate outcomes Knowledge Inquiry Assess supports/ barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Assess barriers/ supports to knowledge use

41. To understand barriers and facilitators to adopting a recommendation consider the perspective of an end-user – Why would I/we adopt this recommendation and how easily can I/we adapt it? Does this recommendation make sense? (do I believe the evidence; does this align with what other respected sources are saying, does my experience support that this is the “right” thing to do? ) If I change will it make an important difference to my patients’ well-being? How close is it to what I already do? Does it fit with how we do things around here? How disruptive will this be to my regular practice? Do I have the support I need in my practice or (in the system) to make this change? When I weigh the pros and cons of whether to adopt the new recommendation, which side wins?

42. What are the barriers/supports to uptake related to the innovation (best practice/guideline), adopters, practice setting/context?

43. The innovation/practice guideline/evidence Development process Attributes of the innovation

44. Development Process • Credible developers • all relevant stakeholders • interdisciplinary • Objective & rigorous method • Careful documentation • Explicit & transparent process • Local involvement

45. Characteristics of the Innovation • Relative advantage (useful) • Low complexity (ease of use or do) • Compatible • (fits with current practice, norms/values) • (Does not demand change in existing practice) • Trialability (easy to try) • Clear (not vague or non-specific) • Evidence-based (Rogers 1995) (Grilli and Lomas, 1994) (Grol et al 1998) (Foy et al 2003)

46. Potential Adopters Awareness Attitudes/intention Knowledge/Skills Concerns (Squires et al. 2011; Graham, Logan, Harrison, Nimrod 2004) Which of these adopter characteristics can be anticipated and addressed while trying to move research knowledge into practice?

47. Practice Environment/context Structural Factors • Decision-making • Policies, rules, laws • Available technology • Physical layout • Availability of evidence • Work pressure • Current practice

48. Culture & belief systems Leadership Politics & personalities Peer influence (Gifford, Davies, Edwards, Graham, 2006; Greenhalgh et al., 2004) Practice Environment/contextSocial Factors

49. Practice Environment/contextOther Factors Patient/Consumers/Clients Behavior, attitudes, preferences, pressure Economic Considerations Resources, remuneration, funding systems Medical/Legal Issues Other Organizational/System Factors

50. Monitor Knowledge Use Select, Tailor, Implement Interventions KNOWLEDGE CREATION Evaluate outcomes Knowledge Inquiry Assess Barriers to Knowledge Use Synthesis Sustain Knowledge Use Products/ Tools Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge Tailoring Knowledge Assess Barriers to Knowledge Use Approach to barriers assessment included: Example • Knowledge, attitudes and practice (KAP) surveys of nurses and physicians (barriers to the guideline) • Practitioner/policy maker feedback on adapted care protocol (barriers to the potential adopters) • Discussions with providers and managers (barriers in the practice environment) (Graham, Harrison, Friedberg et al. 2001; Graham, Harrison, Shafey et al. 2003) • Interviews using the theoretical domains framework