TEACH

Teaching Evidence Assimilation for Collaborative Health Care Capacity Building for Knowledge Based Improvement

Peter Wyer MD Chair, Section on Evidence Based Health Care New York Academy of Medicine

TEACHING EVIDENCE ASSIMILATION FOR COLLABORATIVE HEALTHCARE

ACKNOWLEDGEMENTS TEACH TEAM

LIBRARIANS

INTERNATIONAL ADVISORS

NYAM TEAM

Saadia Akhtar

Louise Falzon

Ian Graham

Eileen Budd

Barney Eskin

Pat Gallagher

Dave Davis

Donna Fingerhut

Eddy Lang

Pattie Mongelia

John Lavis

Francine Leinhardt

Judy Honig

Dorice Vieira

Sharon Straus

Sharon Ching

Aleksandr Tichter

Jamie Graham

Yngve Falck-Ytter

Tawana Wright

Suzana Alves Silva

Yingting Zhang

Arlene Smaldone Craig Umscheid TJ Jirasevijinda Stewart Wright

Claudette Dykes-Brown

TEACHING EVIDENCE ASSIMILATION FOR COLLABORATIVE HEALTHCARE

DISCLOSURES No Faculty Disclosures Declared Generous Donation of Electronic Resources: Annals of Internal Medicine (ACP Journal Club) BMJ Group (Clinical Evidence, Evidence Based Nursing) EBSCO (Dynamed, CINAHL) McGraw-Hill-JAMA (JAMA Evidence) Wolters Kluwer (OVID, UpToDate)

Who Are We? The Section on Evidence Based Health Care at the New York Academy of Medicine

Objectives: Capacity Building • Patient centered care • Responsiveness to change • Knowledge based improvement

TEACHING (EVIDENCE ASSIMILATION) • Evidence Based Practice • Clinical Policies, Recommendations • Knowledge Translation/Implementation

TEACHING (EVIDENCE ASSIMILATION) •

Evidence Based Practice

• Individual patients

•

Clinical Policies, Recommendations

• Populations

•

Knowledge Translation/Implementation • Systems

TEACHING

(EVIDENCE ASSIMILATION)

• Basic, or Foundational, Skills

•

Individual patients

• Reviews, Appraising/adapting guidelines • Populations • Knowledge creation, implementation

•

Systems

TEACHING

(EVIDENCE ASSIMILATION)

• Basic, or Foundational, Skills

LEVEL 1

• Reviews, Appraising/adapting guidelines LEVEL 2 • Knowledge creation, implementation

LEVEL 3

Level 1 • Constructed priorities and preferences • Road Map defining evidence literacy • Narrative, clinical and epidemiological skills

Level 2 • • • • •

Clinical policies and recommendations Specific health care settings Guideline appraisal and adaptation The GRADE system Building in adaptability, actionability

Level 3 • • • • •

Team based problem definition Gathering ‘internal’ + ‘external’ evidence Consider health services, implementation research Monitoring measurable and sustainable impact Maintaining currency

A Common Skill Matrix Across Dimensions • • • • • •

Problem delineation Formulating information needs Finding the most relevant evidence Appraising evidence quality and importance Evaluating relevance, interpreting applicability Assimilation

(Teaching)

Evidence Assimilation

Evidence from research: Lead protagonist or supporting cast?

• • • •

Scientifically informed individualized care Evidence-informed clinical policies Knowledge-based quality improvement The narrative dimension

Scientifically Informed Clinical Practice Within Organized Health Care Settings

Executive

Management

Individual patient care

Clinical policy development

Implementation

Specialties

Team

Practitioners

Care delivery

Patients

The TEACH Experience DRIVERS Clinical/Administrative • Problem driven • Comprehensive team • QI present, subordinated • Systematic approach – Lit review – Chart review – Baseline outcomes

• 18 months to launch • Prize winning results

Quality Improvement • • • •

Intervention driven Limited team QI operationally in charge Shortcuts – Direct planning to implement – No baseline data

• 6 months to launch • Modest results

Attributes

“QI” • • • • • •

vs

Process OC Error Variation Short turn around QI team Industrial standards

“KT” • • • • • •

Patient-centered OC Unnecessary care Innovation Intermediate turn around Organizational engagement Scientific standards

KT

or

QI

Hence: EBM + QI ≠ KBI

MODE Quality Improvement/TQM

CONTENT Process Outcomes (Error reduction Variation decrease)

Clinical Outcomes Knowledge Translation

EXCHANGE Internal Knowledge

External Knowledge

(Adoption of innovation ‘De-adoption’ of unnecessary care)

Nonaka: Organizational Kowledge Creation

Comparative Effectiveness and Practice Based Research: The Frontiers of “EBP” • The importance of local, or ‘internal’ evidence • The importance of practice experience • PBR-blurring the boundary between ‘research’ and ‘practice’ • Classical clinical research remains valuable, frequently crucial, but nontheless indirect