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