Knowledge Translation at the
Canadian Institutes of Health Research
NCDDR Web cast
December 6, 2006
Liz Stirling and Jacqueline Tetroe
Outline for the discussion
1. Knowledge Translation at CIHR
• Definitions, purpose and rationale for knowledge
translation
2. How widely can the concept of knowledge
translation be applied?
3. But what does KT really mean?
4. Knowledge to Action – Graham et al 2006
5. Knowledge Translation – good in theory - how can it
work in practice?
6. How to measure the impact of Knowledge
Translation
7. Moving knowledge to action: Best practice for
wound care
2
Outline for the discussion
1. Knowledge Translation at CIHR
• Definitions, purpose and rationale for knowledge
translation
2. How widely can the concept of knowledge
translation be applied?
3. But what does KT really mean?
4. Knowledge to Action – Graham et al 2006
5. Knowledge Translation – good in theory - how can it
work in practice?
6. How to measure the impact of Knowledge
Translation
7. Moving knowledge to action: Best practice for
wound care
3
Knowledge Translation at CIHR
Definitions, purpose and rationale for knowledge
translation
Knowledge translation is the exchange, synthesis and
ethically-sound application of knowledge - within a
complex system of interactions among researchers and
users - to accelerate the capture of the benefits of
research for Canadians through improved health, more
effective services and products, and a strengthened
health care system
4
Knowledge Translation at CIHR
Definitions, purpose and rationale for knowledge
translation
Context for the CIHR definition
As described in the CIHR Act, knowledge translation is a
broad concept. It encompasses all steps between the
creation of new knowledge and its application to yield
beneficial outcomes for society. This includes
knowledge dissemination, communication, technology
transfer, ethical context, knowledge management,
knowledge utilization, two-way exchange between
researchers and those who apply knowledge,
implementation research, technology assessment,
synthesis of results within a global context,
development of consensus guidelines, and more.
5
Knowledge Translation at CIHR
Definitions, purpose and rationale for knowledge
translation
Key point is that interactions between
researchers and stakeholders may vary in
intensity, complexity and level of
engagement depending on the nature of the
research results and on the needs of the
particular stakeholder.
6
Knowledge Translation at CIHR
Definitions, purpose and rationale for knowledge
translation
What is NOT KT?
For example, KT is NOT:
Continuing Medical Education
Continuing Professional Development
Translational Research
7
Knowledge Translation at CIHR
Definitions, purpose and rationale for knowledge
translation
What is Continuing Medical Education?
CME generally refers to planned educational
activities intended to further the education
and training of specific health professionals
for the enhancement of practice, education,
administration and research or Professional
Development
8
Knowledge Translation at CIHR
Definitions, purpose and rationale for knowledge
translation
What is Continuing Professional Development?
This includes educational methods beyond the
didactic, embodies concepts of self-directed
learning and personal development and
considers organizational and system factors
9
Knowledge Translation at CIHR
Definitions, purpose and rationale for knowledge
translation
What is Translational Research?
Translational research is about finding
solutions to clinical problems. Ideally it
involves two way interactions between
basic/fundamental scientists and clinicians
and requires moving between scientific
discoveries and clinical applications
10
Knowledge Translation at CIHR
Definitions, purpose and rationale for knowledge
translation
The distinction between translational research
and KT is that KT is the next step in the
process - the widespread dissemination of the
clinical application once it has been proven
beneficial by clinical research would be
considered KT (i.e. translational research ends
with the development and/or testing of the
clinical application and does not include its
widespread promotion).
11
Knowledge Translation at CIHR
Definitions, purpose and rationale for knowledge
translation
The rationale for KT:
1.
Creation of new knowledge often does not, by
itself, lead to its widespread adoption or impact
health
2.
Increased emphasis on research governance and
accountability from many levels: federal and
provincial government, as well as the public
12
Knowledge Translation at CIHR
Definitions, purpose and rationale for knowledge
translation
3.
The mandate of CIHR includes KT:
To excel, according to internationally accepted standards of
scientific excellence, in the creation of new knowledge
and its translation into improved health for Canadians,
more effective health services and products and a
strengthened Canadian health care system."
4.
To move research into practice/action
and ultimately,
5.
To improve the health of Canadians.
13
Knowledge Translation at CIHR
Definitions, purpose and rationale for knowledge
translation
14
Historical perspective of KT in Canadian Health
funding organizations:
• The Alberta Heritage Foundation for Medical
Research started to identify the need in the early
1990’s, using the term “research in practice” –
and developed a model
• The Canadian Health Services Research
Foundation– founded in 1996 – focused on
linkage and exchange and knowledge brokering
and brought these concepts into academic
forums
• Change from MRC to CIHR in 2000 – KT became
part of the mandate
Outline for the discussion
1. Knowledge Translation at CIHR
• Definitions, purpose and rationale for knowledge
translation
2. How widely can the concept of knowledge
translation be applied?
3. But what does KT really mean?
4. Knowledge to Action – Graham et al 2006
5. Knowledge Translation – good in theory - how can it
work in practice?
6. How to measure the impact of Knowledge
Translation
7. Moving knowledge to action: Best practice for
wound care
15
How widely can the concept of knowledge
translation be applied?
• KT is an issue at the local, national and
international level
• What distinguishes the levels is the end
user/target audience
• The process is essentially the same at each
level
• The impact of KT can filter up or down the
levels
• In our view, we need to link globally and act
locally
16
How widely can the concept of knowledge
translation be applied?
• KT is not unique to medical research
• The concept has been used in many other
disciplines – and is known by other names:
technology transfer, knowledge
management, change management etc.
• The process that is KT is appropriate to any
discipline – it is about facilitating the uptake
of research
• While the process is universal, the
content/context does vary
17
Outline for the discussion
1. Knowledge Translation at CIHR
• Definitions, purpose and rationale for knowledge
translation
2. How widely can the concept of knowledge
translation be applied?
3. But what does KT really mean?
4. Knowledge to Action – Graham et al 2006
5. Knowledge Translation – good in theory - how can it
work in practice?
6. How to measure the impact of Knowledge
Translation
7. Moving knowledge to action: Best practice for
wound care
18
But what does KT really mean?
How does the term KT differ from the term research
utilization?
• Depends on how one defines :”research” and on
how one defines “knowledge”
• We think of research as a subset of knowledge
• We are not getting involved in the debate over the
definition of “evidence”1
1 See,
for example: Conceptualizing and combining evidence for health
system guidance. http://www.chsrf.ca/other_documents/evidence_e.php
19
But what does KT really mean?
Knowledge translation versus research utilization
continued
• Starting in the early 1970s, research utilization was
the term used to describe the incorporation of
research evidence into clinical practice.
• Since then, many nursing models of research
utilization have been developed.
20
But what does KT really mean?
What is meant by research utilization?
• A term used predominantly by the nursing
professions
• The definition has become more precise over time
• A process of using findings from conducting
research, to guide practice – Titler et al 1999
• The process by which scientifically produced
knowledge is transferred to practice – Brown 1999
21
But what does KT really mean?
Definition of research utilization continued
• The use of research findings in any and all aspects
of one’s work as a registered nurse – Estabrooks
1998
• Process by which specific research-based
knowledge (science) is implemented in practice Estabrooks 2003
• A specific kind of knowledge utilization whereby the
knowledge has a research base to substantiate it. It
is a complex process in which knowledge, in the
form of research, is transformed from the findings of
one or more studies into instrumental, conceptual,
or persuasive utilization - Estabrooks 2006
22
But what does KT really mean?




Research utilization
Evidence based practice
Moving knowledge to practice
Knowledge to action
The specific words used are not important per se –
what is important is how these terms are
operationalized
23
But what does KT really mean?




Research utilization
Evidence based practice
Moving knowledge to practice
Knowledge to action
Ian Graham, CIHR Vice President of Knowledge
Translation, uses the term “knowledge to action”2
Knowledge to action is an organic process with
defined steps - it is a process
2
Graham, I.D., Logan, J., Harrison, M., Straus, S., Tetroe, J.M., Caswell, W. and Robinson, N. 2006. Lost in
translation: Time for a map? Journal of Continuing Education in the Health Professions 26:13-24
24
Outline for the discussion
1. Knowledge Translation at CIHR
• Definitions, purpose and rationale for knowledge
translation
2. How widely can the concept of knowledge
translation be applied?
3. But what does KT really mean?
4. Knowledge to Action – Graham et al 2006
5. Knowledge Translation – good in theory - how can it
work in practice?
6. How to measure the impact of Knowledge
Translation
7. Moving knowledge to action: Best practice for
wound care
25
Knowledge to Action – Graham et al 2006
Knowledge to Action Cycle
Knowledge to Action – Graham et al 2006
How was this model derived?
• The Knowledge Creation “funnel”
• The Action Cycle
27
Knowledge to Action – Graham et al 2006
How was this model derived?
1. The Knowledge Creation “funnel”
• Importance of synthesis
• To contextualize and integrate the findings of
an individual research study within a larger
body of literature.
• Synthesis can take the form of a systematic
review, or follow the methods developed by
the Cochrane Collaboration, or use
quantitative or qualitative methods or result
from a consensus conference or expert
panel.
28
Knowledge to Action – Graham et al 2006
How was this model derived?
1. The Knowledge Creation “funnel”
• Importance of systematic reviews
• Used to create knowledge tools ie provide
the data content for incorporation in practice
guidelines
• Used to determine best practice (that needs
to be implemented)
• To create a context for and establish an
evidence base for the knowledge to be
translated
29
Knowledge to Action – Graham et al 2006
How was this model derived?
1. The Knowledge Creation “funnel”
• Importance of grading evidence within
systematic reviews
• Establishes the credibility of the evidence
base of the knowledge to be “translated”
• Creates a hierarchy of types of evidence to
guide the synthesis of knowledge
30
Knowledge to Action – Graham et al 2006
How was this model derived?
2. The Action Cycle
First – a lesson on implementation theories;
• Classical: passive descriptive models(normative) eg. diffusion theory – used to
retrospectively understand change
• Planned: action models – designed
specifically to be used to bring about change
31
Knowledge to Action – Graham et al 2006
One example of a planned action
theory/framework:
The Ottawa Model of Research Use (OMRU)
• About moving research findings/evidence
into practice
• There are other good models – this is just an
example
32
33
Knowledge to Action – Graham et al 2006
Action categories derived from the constructs
of all the planned action theories we
reviewed:
•
•
•
•
•
•
Identify the problem
Identify the need for change
Identify change agents
Identify target audience
Assess barriers
Review evidence/ literature or develop
innovation
34
Knowledge to Action – Graham et al 2006
Action categories continued…
•
•
•
•
Tailor/develop intervention
Link(age)
Implement
Evaluate
• Develop evaluation plan
• Pilot test
• Evaluate the process
• Evaluate outcomes
• Maintain change
• Disseminate
35
Knowledge to Action – Graham et al 2006
Knowledge to Action Cycle
Outline for the discussion
1. Knowledge Translation at CIHR
• Definitions, purpose and rationale for knowledge
translation
2. How widely can the concept of knowledge
translation be applied?
3. But what does KT really mean?
4. Knowledge to Action – Graham et al 2006
5. Knowledge Translation – good in theory - how can it
work in practice?
6. How to measure the impact of Knowledge
Translation
7. Moving knowledge to action: Best practice for
wound care
37
Knowledge Translation – good in theory - how
can it work in practice?
Who is responsible for what in the knowledge
translation process?
Depends on the particular situation
• The key process to keep in mind is
linkage/communication with key stakeholders
• In cases where implementation (knowledge to action)
is required, ensure agreement on:
• the need for change
• the evidence for change
• methods and the evaluation of the impact of the
change
• as well as who should do what…
38
Knowledge Translation – good in theory - how
can it work in practice?
In what ways can researchers best contribute to the
KT process?
They can:
•
•
•
•
•
•
contribute to the science as well as the practice of KT
conduct needs assessments
conduct systematic reviews pointing to a need for change
create an appetite for research results
keep communication lines open
conduct research with a ready audience having a perceived
need for the research results
• be knowledge brokers
• be systematic and rigorous
39
Knowledge Translation – good in theory - how
can it work in practice?
Role of consumers in knowledge translation
• How they can contribute depends on their role –
are they on the receiving end or are they the
drivers of change?
• In Canada there are many examples of vocal lobby
groups driving political agendas – ie pro choice,
gay marriage, HIV/AIDS research
• At CIHR, for example – the Institute for
Musculoskeletal Health and Arthritis (IMHA)
involves consumers in a number of different ways
40
Outline for the discussion
1. Knowledge Translation at CIHR
• Definitions, purpose and rationale for knowledge
translation
2. How widely can the concept of knowledge
translation be applied?
3. But what does KT really mean?
4. Knowledge to Action – Graham et al 2006
5. Knowledge Translation – good in theory - how can it
work in practice?
6. How to measure the impact of Knowledge
Translation
7. Moving knowledge to action: Best practice for
wound care
41
How to measure the impact of
Knowledge Translation
• How to measure impact is the six million dollar
question – whether it is framed to be about the KT
process or the impact of KT
• Depends on one’s definition and on the perspective of
the stakeholder
• Can develop measures of each step of the K to A
process, but there is no empirical data to suggest
how to weight the various components
• Can assess degree of activity or linkage or use of
knowledge at each of the steps
42
How to measure the impact of
Knowledge Translation
Need to consider types of impact:
• instrumental (applying research results in specific,
direct ways),
• conceptual (using research results for general
enlightenment, results influence actions but more
indirectly and less specifically than in instrumental
use)
or
• symbolic (using research results to legitimate and
sustain predetermined positions)3
3
Beyer, J.M. 1997. Research utilization: Bridging the gap between
communities. Journal of Management Inquiry 6 (1): 17-22.
43
How to measure the impact of
Knowledge Translation
• Canadian Health Services Research Foundation
(CHSRF), and the Alberta Heritage Foundation for
Medical Research (AHFMR) have been making
some progress on the question of assessing
impact, as has CIHR
• CIHR has developed a framework for evaluation
of the impact of the research we fund4
4 Developing
a CIHR Framework to Measure the Impact of Health Research
http://www.cihr-irsc.gc.ca/e/153.html
44
How to measure the impact of
Knowledge Translation
Stakeholders
Perspectives
Higher education
Sector
Academic Excellence
Knowledge production
Capacity building
Health professionals &
Administrators
Effective treatments and diagnostics
Effectiveness and efficiency of the
health care system
Society
•Response to public health threats
•Improved health care
•Improved health status
•Efficiency and sustainability
45
How to measure the impact of
Knowledge Translation
Stakeholders
Perspectives
Industry
Commercial potential
Government
Public health and responses to health
threats
Health status
Contribution to economic growth and
productivity
Efficiency and sustainability of health
systems
46
How to measure the impact of
Knowledge Translation
Examples of sources of data for measuring impact of
knowledge translation
• Citation impact analyses (e.g. bibliometric
studies)
• End-of-Grant reports
• Case studies
• Interviews/surveys
• Administrative data bases
• Document analysis
47
Outline for the discussion
1. Knowledge Translation at CIHR
• Definitions, purpose and rationale for knowledge
translation
2. How widely can the concept of knowledge
translation be applied?
3. But what does KT really mean?
4. Knowledge to Action – Graham et al 2006
5. Knowledge Translation – good in theory - how can it
work in practice?
6. How to measure the impact of Knowledge
Translation
7. Moving knowledge to action: Best practice for
wound care
48
Moving knowledge to action:
Best practice for wound care
•
•
•
•
•
7 year program of research and implementation
Led by Ian Graham and Margaret Harrison5
Community care of venous leg ulcers
Collaborative interdisciplinary approach
Excellent means of illustrating the knowledge to
action cycle
5A
community-researcher alliance to improve chronic wound care
CIHR KT Casebook, (Graham et al, 2006)
http://www.cihr-irsc.gc.ca/e/30669.html
49
Monitor
knowledge
use
Select, tailor
implement
interventions
Knowledge Creation
Evaluate
outcomes
Knowledge
inquiry
Assess barriers
to knowledge
use
Knowledge
synthesis
Knowledge
tools/
products
Adapt knowledge
to local
context
Identify Problem
Identify, Review
Select knowledge
50
Sustain
knowledge
use
Moving knowledge to action:
Best practice for wound care
Leg Ulcers are:
• Common, costly, complex
• Chronic, recurring
• Debilitating, isolating condition
• 80% care reported to be community-based,
delivered by nurses
51
Moving knowledge to action:
Best practice for wound care
Background work to understand the local:
• Population
• Providers, scopes of practice
• Practice environment
• Gaps re: evidence-based practice
Then, formed an alliance between decision-makers,
clinicians (and researchers) for planning, and to
design and conduct a needs assessment
52
Moving knowledge to action:
Best practice for wound care
• High level evidence for assessment and
management of venous ulcers
• Numerous international Clinical Practice Guidelines
available
53
Monitor
knowledge
use
Select, tailor
implement
interventions
Knowledge Creation
Evaluate
outcomes
Knowledge
inquiry
Assess barriers
to knowledge
use
Knowledge
synthesis
Knowledge
tools/
products
Adapt knowledge
to local
context
Identify Problem
Identify, Review
Select knowledge
54
Sustain
knowledge
use
Moving knowledge to action:
Best practice for wound care
10. Scheduled Review and
Revision of Local Guideline
1. Identify a Clinical Area to
Promote Best Practice
9. Official Endorsement
and Adoption of Local
Guideline
2. Establish an
Interdisciplinary Guideline
Evaluation Group
8. Finalize Local Guideline
3. Establish Guideline
Appraisal Process
7. External Review – Practioner
and Policy Maker Feedback;
Expert Peer Review
4. Search and Retrieve
Guidelines
6. Adaptation of
Guidelines for Local Use
5. Guidelines Assessment
a) Quality
b) Currency
c) Content
Practice Guidelines Evaluation and Adaptation Cycle
(Graham et al 1999; Graham et al 2005)
55
Monitor
knowledge
use
Select, tailor
implement
interventions
Knowledge Creation
Evaluate
outcomes
Knowledge
inquiry
Assess barriers
to knowledge
use
Knowledge
synthesis
Knowledge
tools/
products
Adapt knowledge
to local
context
Identify Problem
Identify, Review
Select knowledge
56
Sustain
knowledge
use
Moving knowledge to action:
Best practice for wound care
From the Ottawa Model of Research Use (OMRU) we
know to assess barriers at the level of:
• The guideline
• The potential adopters
• The practice environment
57
Moving knowledge to action:
Best practice for wound care
Approach to barriers assessment included:
• Knowledge, attitudes and practice (KAP) surveys
of nurses and physicians (Graham, Harrison, Friedberg et al.
2001; Graham, Harrison, Shafey et al. 2003)
• Practitioner/policy maker feedback on adapted
care protocol
• Discussions with providers and managers
58
Monitor
knowledge
use
Select, tailor
implement
interventions
Knowledge Creation
Evaluate
outcomes
Knowledge
inquiry
Assess barriers
to knowledge
use
Knowledge
synthesis
Knowledge
tools/
products
Adapt knowledge
to local
context
Identify Problem
Identify, Review
Select knowledge
59
Sustain
knowledge
use
Moving knowledge to action:
Best practice for wound care
Interventions for implementation
1. Provider level
Training for nurses (UK N18 course, doppler & bandaging
training)
2. Practice setting level
Redesigned service delivery for EB leg ulcer care
• dedicated RN leg ulcer care team
• home and clinic
• equipment
• reimbursement alterations
• changes to process for referral to specialists
60
Monitor
knowledge
use
Select, tailor
implement
interventions
Knowledge Creation
Evaluate
outcomes
Knowledge
inquiry
Assess barriers
to knowledge
use
Knowledge
synthesis
Knowledge
tools/
products
Adapt knowledge
to local
context
Identify Problem
Identify, Review
Select knowledge
61
Sustain
knowledge
use
Moving knowledge to action:
Best practice for wound care
Recommendations
Uptake
Pre guideline
adoption
(n = 66)
Post Guideline adoption
(n = 238)
n (%)
n (%)
Identification of Ulcer
Etiology
35 (53)
238 (100)
ABPI prior to initiating
compression
21 (47)
227 (95)
7 (11)
80(88)
Compression bandage
initiated for venous ulcers
44 (66)
148 (86)
Pain Assessment
Documented
10 (15)
215 (90)
Parameters of EBCPG
Serial Ulcer
measurement recorded
62
Monitor
knowledge
use
Select, tailor
implement
interventions
Knowledge Creation
Evaluate
outcomes
Knowledge
inquiry
Assess barriers
to knowledge
use
Knowledge
synthesis
Knowledge
tools/
products
Adapt knowledge
to local
context
Identify Problem
Identify, Review
Select knowledge
63
Sustain
knowledge
use
Moving knowledge to action:
Best practice for wound care
Evaluation of outcomes
64
Moving knowledge to action:
Best practice for wound care
Pre-post Evaluation of Outcomes
(Harrison, Graham, Lorimer et. al CMAJ 2005)
3 month healing rate: 23% → 56%
Nursing Visits
• median 3 → 2.1/wk
• daily visiting decreased from 38% → 6%
Supply costs
• Median per case: $1923 → $406
65
Monitor
knowledge
use
Select, tailor
implement
interventions
Knowledge Creation
Evaluate
outcomes
Knowledge
inquiry
Assess barriers
to knowledge
use
Knowledge
synthesis
Knowledge
tools/
products
Adapt knowledge
to local
context
Identify Problem
Identify, Review
Select knowledge
66
Sustain
knowledge
use
Moving knowledge to action:
Best practice for wound care
Sustainability still under investigation:
• Protocol expanded to 3 other regions
• RCT underway of home vs clinic care
• RCT underway of two compression technologies
67
Moving knowledge to action:
Best practice for wound care
Lessons learned:
• Moving knowledge to action is an iterative
process of using external evidence and producing
local ‘evidence’ for planning
• Successful implementation requires
• Strategic alliances between researchers &
health setting
• Population health principles
• Needs-based planning
• Working at both clinical and health services
levels
68
Moving knowledge to action:
Best practice for wound care
Lessons learned continued:
In moving research to action the role of the
researcher is to:
create & facilitate a strategic alliance and a
problem-focused collaboration
bring “science of synthesis” to practice
use rigorous methods for each step
(organizational planning, guideline appraisal &
adoption, evaluation of the implementation)
use conceptual frameworks to underpin the
research
69
In conclusion
Knowledge Translation is:
• Collaborative
• Iterative
• Complex
• Time consuming
• Never really completed
It requires:
• Persistence
• Patience
• Expertise with multiple research methods
• Problem solving skills
• People skills
70