Translating Evidence
into Practice
Sean M. Berenholtz, MD MHS FCCM
Johns Hopkins University
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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?
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
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RAND Study Confirms Continued Quality Gap
Condition
Percentage of
Recommended Care Received
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edit Master text styles
Low backto
pain
68.5
artery disease
–Coronary
Second
level
68.0
• Third
Depression
57.7
Hypertension
64.7
level
Orthopedic–conditions
Fourth level
57.2
Colorectal cancer
» Fifth level
Asthma
53.9
Benign prostatic hyperplasia
53.0
Hyperlipidemia
48.6
Diabetes mellitus
45.4
Headaches
45.2
Urinary tract infection
40.7
Hip fracture
22.8
Alcohol dependence
10.5
53.5
McGlynn et al, NEJM 2003; 348(26):2635-26454
Approaches to Improve TRiP
Approach
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
Adopted from Grol R. JAMA 2001;286:2578-2585.
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• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level
Grol R. JAMA 2001;286:2578-2585
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• Click to edit Master text styles
– Second level
• Third level
– Fourth level
» Fifth level
BMJ 2008;337:963-965.
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;337:963-965.
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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):305-314.
• Venous Thromboembolism (VTE)
– Arch Surg. 2012;147(10):901-907.
• Colorectal Surgical Site Infections (SSI)
– J Am Coll Surg. 2012;215(2):193-200.
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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: 500 - 4,000
• Cost per episode: $28,690-$56,000
• Annual cost: $60 - $460 million
CDC. MMWR 2002; Heiselman JAMA 1994;
Dimick Arch Surg 2001
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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)
Cabana et al. JAMA 1999
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
www.cdc.gov
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Standardize
Care
•
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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Creating Reliable Health Care
Executive
Leaders
Team
Leaders
Staff
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Engage
How Does This Make the World a Better Place?
– Second level
• Third level
Educate
– Fourth level
What
Do We Need to Do?
» Fifth level
Execute
How can we do it with my resources and culture?
Evaluate
How Do We Know We Made a Difference?
Health Services Research 2006
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CLA-BSI Rate Per 1,000 CL. Days
CLABSI Rate for All ICUS at JHH:
1998 - Q2 2012
13.00
12.00
11.00
10.00
9.00
8.00
7.00
6.00
5.00
4.00
3.00
2.00
1.00
-
1998
All ICUs 11.82
1999
7.51
2000
6.86
2001
7.90
2002
4.24
2003
2.53
2004
2.25
2005
2.33
2006
2.73
2007
1.67
2008
1.34
2009
1.22
2010
1.59
2011
0.88
Crit Care Med 2004;32(10):2014
2012
0.90
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Michigan Keystone ICU
CLABSI Rate: 2004-2012
N Engl J Med 2006;355:2725-32;
BMJ 2010;340:c309.
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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.
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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
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Key Concepts:
Technical and Adaptive Work
Technical
Work
Evidence-based
interventions
Sweet
Spot
Adaptive
Work
Local culture
How Will We Get There?
TECHNICAL WORK
ADAPTIVE WORK
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Work that
we know we
should do,
– Second
level
like appropriate antibiotic dosing
• Third level
and skin preparation
– Fourth level
» Fifth level
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
Learning, Development, and
Capacity
Target:
People aiming
for a career
in safety- quality work
- Graduate degrees
- Career development awards
Target: Healthcare leaders /managers
with responsibility for improving safety-quality
- Patient Safety Certificate
- Safety fellows
Target: All healthcare professionals
- Medical, nursing , and other healthcare professions’ students
- Residents , fellows
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AI Patient Safety Training
• Online Patient Safety
Certificate
– 13 modules, 18 hours
• Patient Safety
Certificate Program
– 24 modules, 5
consecutive days
• Patient Safety
Fellowship
– 6 months, didactic,
mentorship
• Analytics Leadership in
Patient Safety
– 12 months, didactic,
mentorship
For more, visit
http://www.hopkinsmedicine.org/armstrong_institute/programs/
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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COMPREHENSIVE UNIT-BASED
SAFETY PROGRAM (CUSP)
A practical approach to tap into the wisdom of frontline
staff and improve teamwork and safety culture
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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
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CUSP Objectives
Comprehensive Unit-based Safety Program
1. Educate staff on science of safety
2. Identify defects
3. Partner with a senior executive
4. Learn from defects
5. Improve teamwork and communication
Jt Comm J Qual Patient Saf 2010;36:252-60
Resources: http://www.ahrq.gov/cusptoolkit/
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Statewide Michigan CUSP ICU Results
"Needs Improvement”
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• Needs Improvement:
Less than 60% of
respondents reporting
good safety or teamwork
climate
• Statewide in 2004 8284% needed
improvement, down to
22-23% in 2007
90
80
84%
82%
70
60
50
40
30
20
10
23%
22%
0
Safety Climate
Before
Teamwork Climate
After
J Critical Care 2008;23:207-221
Crit Care Med 2011;39(5):1-6
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Best Way Forward
• Harm is preventable
– 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
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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.
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