1 Practicing Knowledge Translation: Implementing Evidence. Achieving Outcomes. HSR Satellite Session November 14, 2016 Dr. Julia E. Moore & Dr. Sharon Straus

2 Today’s Roadmap Presentation 1: What is knowledge translation?Activity 1: Learning goals Presentation 1: What is knowledge translation? Activity 2: Dissemination or implementation Presentation 2: How do we bring research to practice? Activity 3: What do you want to change? Presentation 3: Identify barriers and facilitators to change Activity 4: Why would people change (or not change)? Presentation 4: Mapping barriers and facilitators Activity 5: Mapping barriers and facilitators Presentation 5: Implementation strategies Activity 6: Select implementation strategies

3 Course Developers Julia E. Moore, MSc, PhD Sobia Khan, MPHSharon E. Straus, MD, MSc, FRCPC

4 Learning Objectives Presentation 1: Introduction to KTDefine knowledge translation (KT) Identify differences between dissemination and implementation Presentation 2: Bringing research to practice Describe the knowledge-to-action model (KTA) Explain important aspects of designing an evidence-informed, theory-driven program (ETP) Presentation 3: Identify barriers & facilitators to change Describe how to assess barriers & facilitators to change Identify barriers and facilitators related to the practice change Presentation 4: Mapping barriers & facilitators Explain how to map barriers & facilitators to the Theoretical Domains Framework Describe COM-B Presentation 5: Implementation strategies Define implementation strategies Systematically select implementation strategies Stuart Miles/freedigitalphotos.net

5 Activity #1: Setting Learning GoalsYou have 15 minutes to: Use the ‘Setting Learning Goals’ worksheet to identify some concrete learning goals for this workshop. (5 minutes) Discuss learning goals in pairs/small groups. (5 minutes) Discuss learning goals as a large group. (5 minutes) 1 2 3

6 Activity #1: DiscussionWhat are some of your learning goals for this workshop?

7 Presentation 1: What is Knowledge Translation?

8 What is Knowledge Translation?dynamic and iterative process includes synthesis, dissemination, exchange and ethically sound application of knowledge improves health services and products, and strengthen the health care system takes place within a complex system of interaction CIHR definition (www.cihr-irsc.gc.ca/e/29418.html)

9 Why does KT matter? Balas E, Boren S. Managing Clinical Knowledge for Health Care Improvement. In: van Bemmel JH, McCray AT, eds. Yearbook of Medical Informatics. Stuttgart: Schattauer Verlagsgesellschaft mbH, 2000:65–70

10 Why does KT matter? = 87.5% wastedIt is estimated that approximately 85% of research resources are wasted Low priority questions addressed Important outcomes not assessed For every 100 projects: 50 not published 25 not usable or replicable 12.5 have serious design flaws = 87.5% wasted Sira Anamwong/freedigitalphotos Chalmers & Glasziuo (2009) Avoidable waste in the production and reporting of research evidence.

11 Different Terms for KT

12 The Knowledge to Action ModelSource: Graham ID et al. JCHEP 2006;26:13-24.

13 Knowledge Creation FunnelThe knowledge creation funnel conveys the idea that knowledge needs to be increasingly distilled before it is ready for application Knowledge Inquiry: First generation knowledge (e.g., broad base primary studies or information) Knowledge Synthesis: Methodologies for determining what is known in a given area or field and what the knowledge gaps are (e.g., systematic reviews) Knowledge Tools/Products: Refined knowledge for decision-making (e.g., guidelines, decision aids, algorithms) Source: Graham ID et al. JCHEP 2006;26:13-24.

14 The Action Cycle The action cycle emphasizes the dynamic action steps needed to apply the knowledge created (in any sequence). It is intended to deliberately cause change. Source: Graham ID et al. JCHEP 2006;26:13-24.

15 The Knowledge to Action ModelKnowledge creation, distillation and dissemination are not sufficient to ensure behaviour change… We need to effectively implement!

16 KT: Dissemination and ImplementationPractice Dissemination Implementation Science Dissemination Practice Purposive distribution of information and intervention materials to a specific audience. The intent is to spread information. (NIH) Implementation Practice The use of strategies to adopt and integrate evidence-based interventions and change practice within specific settings. (NIH) Dissemination Science The scientific study of processes and variables that determine and/or influence the spread/sharing of knowledge to various stakeholders. (NIH) Implementation Science The scientific study of the methods to promote the uptake of research findings in clinical, organizational, or policy contexts. (Implementation Science journal) Knowledge Translation Dissemination and Implementation Science. (n.d.). National Institutes of Health. Retrieved September 21, 2015, from https://www.nlm.nih.gov/hsrinfo/implementation_science.html; Implementation Science. Retrieved September 21, 2015, from

17 Activity #2: Dissemination or implementation?You have 15 minutes to: As a group, read the  following examples of projects and determine whether they constitute dissemination practice, implementation practice, dissemination science, or implementation science. 1

18 Knowledge Translation1. Creating rapid heart failure clinics in hospitals that see patients within 48 hours after being discharged following a heart attack. Practice Dissemination Implementation Science Dissemination Practice Purposive distribution of information and intervention materials to a specific audience. The intent is to spread information. (NIH) Implementation Practice The use of strategies to adopt and integrate evidence-based interventions and change practice within specific settings. (NIH) Dissemination Science The scientific study of processes and variables that determine and/or influence the spread/sharing of knowledge to various stakeholders. Implementation Science The scientific study of the methods to promote the uptake of research findings in clinical, organizational, or policy contexts. (Implementation Science journal) Knowledge Translation

19 Knowledge Translation2. Comparing two different website layouts to determine which format patients find more usable. Practice Dissemination Implementation Science Dissemination Practice Purposive distribution of information and intervention materials to a specific audience. The intent is to spread information. (NIH) Implementation Practice The use of strategies to adopt and integrate evidence-based interventions and change practice within specific settings. (NIH) Dissemination Science The scientific study of processes and variables that determine and/or influence the spread/sharing of knowledge to various stakeholders. Implementation Science The scientific study of the methods to promote the uptake of research findings in clinical, organizational, or policy contexts. (Implementation Science journal) Knowledge Translation

20 Knowledge Translation3. Developing and distributing policy briefs and research summaries to policy makers. Practice Dissemination Implementation Science Dissemination Practice Purposive distribution of information and intervention materials to a specific audience. The intent is to spread information. (NIH) Implementation Practice The use of strategies to adopt and integrate evidence-based interventions and change practice within specific settings. (NIH) Dissemination Science The scientific study of processes and variables that determine and/or influence the spread/sharing of knowledge to various stakeholders. Implementation Science The scientific study of the methods to promote the uptake of research findings in clinical, organizational, or policy contexts. (Implementation Science journal) Knowledge Translation

21 Knowledge Translation4. Health facilities were provided with a set of tools, training and support to decrease staff practices that were associated with hospital-acquired infections. Practice Dissemination Implementation Science Dissemination Practice Purposive distribution of information and intervention materials to a specific audience. The intent is to spread information. (NIH) Implementation Practice The use of strategies to adopt and integrate evidence-based interventions and change practice within specific settings. (NIH) Dissemination Science The scientific study of processes and variables that determine and/or influence the spread/sharing of knowledge to various stakeholders. Implementation Science The scientific study of the methods to promote the uptake of research findings in clinical, organizational, or policy contexts. (Implementation Science journal) Knowledge Translation

22 Knowledge Translation5. A professional association collaborated with provincial agencies to make sure health care professionals represented by the association had received copies of their new clinical guidelines. Practice Dissemination Implementation Science Dissemination Practice Purposive distribution of information and intervention materials to a specific audience. The intent is to spread information. (NIH) Implementation Practice The use of strategies to adopt and integrate evidence-based interventions and change practice within specific settings. (NIH) Dissemination Science The scientific study of processes and variables that determine and/or influence the spread/sharing of knowledge to various stakeholders. Implementation Science The scientific study of the methods to promote the uptake of research findings in clinical, organizational, or policy contexts. (Implementation Science journal) Knowledge Translation

23 Knowledge Translation6. A group wants to evaluate whether knowledge brokers are effective at supporting behaviour change in community organizations. Practice Dissemination Implementation Science Dissemination Practice Purposive distribution of information and intervention materials to a specific audience. The intent is to spread information. (NIH) Implementation Practice The use of strategies to adopt and integrate evidence-based interventions and change practice within specific settings. (NIH) Dissemination Science The scientific study of processes and variables that determine and/or influence the spread/sharing of knowledge to various stakeholders. Implementation Science The scientific study of the methods to promote the uptake of research findings in clinical, organizational, or policy contexts. (Implementation Science journal) Knowledge Translation

24 Knowledge Translation7. A trial was conducted to determine whether policymakers are more likely to look to guidelines, research summaries, or the media for evidence. Practice Dissemination Implementation Science Dissemination Practice Purposive distribution of information and intervention materials to a specific audience. The intent is to spread information. (NIH) Implementation Practice The use of strategies to adopt and integrate evidence-based interventions and change practice within specific settings. (NIH) Dissemination Science The scientific study of processes and variables that determine and/or influence the spread/sharing of knowledge to various stakeholders. Implementation Science The scientific study of the methods to promote the uptake of research findings in clinical, organizational, or policy contexts. (Implementation Science journal) Knowledge Translation

25 Presentation 2: How do we bring research to practice?

26 The Knowledge to Action ModelSource: Graham ID et al. JCHEP 2006;26:13-24.

27 KT is the key to the black box of “what happened”

28 “ISLAGIATT” principle"The Far Side" by Gary Larson.

29 Operationalizing the KTA: Developing an ETP

30 Consider the evidence for implementation strategiesEvidence-informed theory-driven How confident are we that this activity is a good use of our resources AND improves outcomes? Bumbarger & Rhoades, 2012

31 Evidence-Based WHAT? Evidence-based programs Evidence-based guidelinesProgram comprised of an intervention and implementation strategies that have been systematically evaluated and proven to be effective at producing an outcome. Evidence-based guidelines Outlines recommended practice that is based on systematic review of evidence. Evidence-based implementation strategies/KT interventions Strategies that have been evaluated to implement evidence into practice

32 What if there is no evidence-based program?Evidence-informed theory-driven program (ETP) Practice Change Implementation Strategies Evidence Evidence Theory Practice change must have high-quality research evidence of effectiveness that it can achieve desired outcomes Implementation strategies must be supported by implementation research evidence Implementation strategies must be linked to practice change through behaviour change theory

33 Examples

34 Example: Mobilization of Vulnerable Elders (MOVE)

35 Part A – Define Your GoalsQuestion Example answer: MOVE 1. What is the intended purpose/overall objective of the practice change (i.e., what impact do you hope to see as a result of the practice change)? Improved functional status, ability to return home, decrease length of stay

36 Part A – Define Your GoalsQuestion Example answer: MOVE 2. In which setting(s) is this practice change meant to take place? Hospitals

37 Part A – Define Your GoalsQuestion Example answer: MOVE 3. List all key stakeholders who are expected to change as a result of the implementation. Nurses Allied health professionals Physicians Patients Family members Volunteers

38 Part A – Define Your GoalsQuestion Example answer: MOVE 4. What specific behaviours/practices do each of the stakeholder groups need to make? Assess and document mobility Mobilize patients at least 3 times/day Tailor mobility to patient’s abilities

39 Part A – Define Your GoalsQuestion Example answer: MOVE 5. How often will these stakeholders engage in the changed practice? Multiple times a day, so that everyone is moving at least 3 times a day

40 Part A – Define Your GoalsQuestion Example answer: MOVE 6. What is the evidence for this practice change? Mobilizing patients can improve functional status, decrease length of stay and increase chances of returning home (in hospital settings)

41 Part A – Define Your GoalsQuestion Example answer: MOVE 7. Who will be involved with implementing this change (i.e., making the change happen)? Will create an implementation team on the unit, including nurses, OT/PT, physicians, management

42 Part A – Define Your Goals1. What is the intended purpose/overall objective of the practice change (i.e., what impact do you hope to see as a result of the practice change)? Improved functional status, ability to return home, decrease length of stay 2. In which setting(s) is this practice change meant to take place? Hospitals 3. List all key stakeholders who are expected to change as a result of the implementation. Nurses Physiotherapists/ occupational therapists Physicians Patients Family members Volunteers 4. What specific behaviours/practices do each of the stakeholder groups need to make? Assess and document mobility Mobilize patients at least 3 times/day Tailor mobility to patient’s abilities 5. How often will these stakeholders engage in the changed practice? Multiple times a day, so that everyone is moving at least 3 times a day 6. What is the evidence for this practice change? Mobilizing patients can improve functional status, decrease length of stay and increase chances of returning home (in hospital settings) 7. Who will be involved with implementing this change (i.e., making the change happen)? Will create an implementation team on the unit, including nurses, OT/PT, physicians, management

43 Program Example: MOVE MOVE (Mobilization of Vulnerable Elders)Practice Change Assess and document mobility Mobilize patients at least 3 times/day Tailor mobility to patient’s abilities Implementation Strategies

44 Activity #3: What do you want to change?You have 45 minutes to: 1 Thinking of a project you are working on, or using the example project provided, complete the project outline worksheet. (20 minutes) Exchange your project outline with a partner and provide feedback in the “peer feedback” section of the project outline table. (15 minutes) Discuss as a large group. (10 minutes). 2 3

45 Activity #3: DiscussionDid you experience any challenges when filling out the project outline? What is the specific behaviour/practice change each stakeholder needs to make?

46 Presentation 3: Identifying Barriers & Facilitators to Change

47 Operationalizing the KTA: Developing an ETP

48 Change as Loss Think of change as a potential loss.What might someone lose (or think they are losing)? Heifetz, R., et al. (2009) The Practice of Adaptive Leadership. Boston: Harvard Business Press.

49 Identify Barriers and FacilitatorsAssess barriers & facilitators Identify Barriers and Facilitators Surveys Interviews/ focus groups Observations Discussions with key stakeholders Literature Reviews

50 Barriers and Facilitators: MOVEBarrier: “It’s not my job to move patients, that’s what physiotherapists are for.” Barrier: “I’m afraid patients will fall if we get them moving.” Facilitator: “Once I started encouraging patients to get up, many did it on their own. It was great to see changes happen so quickly.”

51 Levels of Assessment Population/country/province Organization ProviderPatient/family

52 Barriers to Practice Change vs. Barriers to ImplementationMOVE (Mobilization of Vulnerable Elders) Practice Change Assess mobility within 24 hours of admission Each patient mobilized at least 3 times a day Mobility is tailored to patient’s abilities Implementation Strategies

53 Facilitators Remember to assess facilitators as well as barriers.

54 Activity #4: Why would people change (or not change)?You have 45 minutes to: Brainstorm 10 barriers/facilitators for your project. Write these ETP Mapping Worksheet #1. (15 minutes) Discuss your barriers/facilitators with a partner/in small group. (15 minutes) Discuss as a large group. (15 minutes) 1 2 2 3

55 Activity #4: DiscussionWhat are some barriers and facilitators you identified? Are they all about the practice change (i.e., do any relate to implementation)?

56 Presentation 4: Mapping Barriers & Facilitators

57 Operationalizing the KTA: Developing an ETP

58 Question Are you familiar with the Theoretical Domains Framework?

59 Map Barriers and Facilitators to Framework – Theoretical Domains Framework (TDF)What do frameworks do? Help us understand and/or explain influences on implementation and outcomes Why use a behaviour change framework? To understand barriers and facilitators To create surveys or interview guides Knowledge Skills Social/ Professional Role and Identity Beliefs about Capabilities Optimism Beliefs about Consequences Reinforcement Intentions Goals Memory, Attention and Decision Processes Environmental Context and Resources Social Influences Emotion Behavioural Regulation Cane et al. (2012). Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science, 7(1), 37.

60 Mapping Barriers and Facilitators to TDF - MOVEsBarrier: “I’m afraid patients will fall if we get them moving.” Knowledge Skills Social/ Professional Role and Identity Beliefs about Capabilities Optimism Beliefs about Consequences Reinforcement Intentions Goals Memory, Attention and Decision Processes Environmental Context and Resources Social Influences Emotion Behavioural Regulation

61 Mapping Barriers and Facilitators to TDF - MOVEsBarrier: “It’s not my job to move patients, that’s what physiotherapists are for.” Knowledge Skills Social/ Professional Role and Identity Beliefs about Capabilities Optimism Beliefs about Consequences Reinforcement Intentions Goals Memory, Attention and Decision Processes Environmental Context and Resources Social Influences Emotion Behavioural Regulation

62 Mapping Barriers and Facilitators to TDF - MOVEsFacilitator: “Once I made the decision to change and put a little effort in, I immediately saw benefits. Patients were getting up on their own most of the time, it was amazing!” Knowledge Skills Social/ Professional Role and Identity Beliefs about Capabilities Optimism Beliefs about Consequences Reinforcement Intentions Goals Memory, Attention and Decision Processes Environmental Context and Resources Social Influences Emotion Behavioural Regulation

63 Mapping Barriers and Facilitators to TDF – CTFPHCBarrier: “I normally follow the recommendations my colleagues use, but some use national and some use provincial guidelines, so then what do I do?” Knowledge Skills Social/ Professional Role and Identity Beliefs about Capabilities Optimism Beliefs about Consequences Reinforcement Intentions Goals Memory, Attention and Decision Processes Environmental Context and Resources Social Influences Emotion Behavioural Regulation Cane et al. (2012). Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science, 7(1), 37.

64 Mapping Barriers and Facilitators to TDF – CTFPHCBarrier: “I’m afraid of missing a diagnosis .” Knowledge Skills Social/ Professional Role and Identity Beliefs about Capabilities Optimism Beliefs about Consequences Reinforcement Intentions Goals Memory, Attention and Decision Processes Environmental Context and Resources Social Influences Emotion Behavioural Regulation Cane et al. (2012). Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science, 7(1), 37.

65 Mapping Barriers and Facilitators to TDF – CTFPHCFacilitator: “Knowing that well-known experts in the field use CTFPHC guidelines gives me more confidence that I should use them too.” Knowledge Skills Social/ Professional Role and Identity Beliefs about Capabilities Optimism Beliefs about Consequences Reinforcement Intentions Goals Memory, Attention and Decision Processes Environmental Context and Resources Social Influences Emotion Behavioural Regulation Cane et al. (2012). Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science, 7(1), 37.

66 ETP Mapping Worksheet #1: MOVE ExampleBarrier/facilitator TDF Domain COM-B Construct  “I’m afraid patients will fall if we get them moving.” Beliefs about consequences; emotion  “It’s not my job to move patients, that’s what physiotherapists are for.”  Social/Professional role and identity  “Once I made the decision to change and put a little effort in, I immediately saw benefits. Patients were getting up on their own most of the time, it was amazing!”  Reinforcement

67 Behaviour Change Theory

68 Question Are you familiar with any behaviour change theories?

69 How do we change our thinking?

70 Behaviour Change Theory (COM-B)What do theories do? Predict and understand causal mechanisms Why use a behaviour change theory? To understand how people will change Source: Michie S, Atkins L, West R: The behaviour change wheel: a guide to designing interventions. Great Britain: Silverback Pub; 2014.

71 Capabilities - ExampleMOVE: Knowing how to use hoyer

72 Opportunities - ExampleMOVE: Working in an organization/environment that encourages elderly patients to be moved/move

73 Motivation - Example MOVE: Belief that mobilization is their role

74 COM-B and TDF COM-B TDF Capability (Psychological) Knowledge SkillsKnowledge Skills Memory/Decision processes Behavioural regulation Capability (Physical) Opportunity (Physical) Environmental context/resources Opportunity (Social) Social influences Motivation (Reflective) Beliefs about capabilities Beliefs about consequences Social/Professional role/identity Optimism Intentions Goals Motivation (Automatic) Emotion Reinforcement

75 ETP Mapping Worksheet #1: MOVE ExampleBarrier/facilitator TDF Domain COM-B Construct  “I’m afraid patients will fall if we get them moving.” Beliefs about consequences; emotion  Motivation  “It’s not my job to move patients, that’s what physiotherapists are for.”  Social/Professional role and identity  “Once I made the decision to change and put a little effort in, I immediately saw benefits. Patients were getting up on their own most of the time, it was amazing!”  Reinforcement

76 Alternative Behaviour Change TheoriesTheory of Planned Behaviour Diffusion of Innovation Theory The Social Cognitive Theory Transtheoretical Model (Stages of Change) Social Norms Theory

77 KT Requires a Shift in ThinkingLetting it happen Helping it happen Making it happen National Implementation Research Network. (n.d.). Retrieved September 21, 2015, from

78 Activity 5: Mapping Barriers & FacilitatorsYou have 40 minutes to: Map your previously identified barriers and facilitators to the appropriate TDF domains. (20 minutes) Then fill-in the appropriate COM-B categories that your barriers and facilitators map to. (10 minutes) Discuss COM-B and TDF mapping as a large group. (10 minutes) 1 2 3

79 COM-B and TDF COM-B TDF Capability (Psychological) Knowledge SkillsKnowledge Skills Memory/Decision processes Behavioural regulation Capability (Physical) Opportunity (Physical) Environmental context/resources Opportunity (Social) Social influences Motivation (Reflective) Beliefs about capabilities Beliefs about consequences Social/Professional role/identity Optimism Intentions Goals Motivation (Automatic) Emotion Reinforcement

80 Activity #5: DiscussionDid mapping your barriers & facilitators change your thinking about your project? Did you face any challenges when mapping barriers & facilitators? Were you surprised by any of the TDF constructs that your barriers and facilitators mapped to? Which of the constructs (capability, opportunity, or motivation) did most of your barriers/facilitators map to?

81 Presentation 5: Implementation strategies

82 Implementation strategiesMethods or techniques used to enhance the adoption of a clinical practice change. Proctor et al., (2013) Implementation strategies: recommendations for specifying and reporting

83 Examples of Implementation StrategiesAudit & feedback Needs an actionable message to be effective Reminders Reminder fatigue Effects disappear when reminder is removed Education materials Cheap, easy, small behaviour change

84 Types of implementation strategiesDiscrete strategy: consists of 1 component Example: reminders Muliti-faceted strategies: combining a number of strategies Example: educational meeting, educational materials, audit and feedback, Proctor et al., (2013) Implementation strategies: recommendations for specifying and reporting

85 Types of Implementation StrategiesControlling vs. facilitating Voluntary vs. non-voluntary Target audience(s): Health professionals Organizations Consumers/patients/public Policymakers Reference: Grol 2005; Proctor 2009; EPOC; Neilsen at GIC

86 Implementation strategies: ChallengesNames: Multiple meanings for the same term Different terms with the same or similar meanings Definitions: Poorly described/conceptually defined Lack operational definitions and manuals to guide their use Proctor et al., (2013) Implementation strategies: recommendations for specifying and reporting

87 Implementation Strategy SourcesEPOC (2015) Powell (2015) Rx for Change (up to 2013) Dunton (2010) Abraham (2008) Leeman (2007) Maibach (2007) EPOC (2002) Perdue (2005) Psi (2004) Walter (2003) Choen (2000) Vlek (2000) Goel (1996) Geller (1990)

88 Common Implementation StrategiesAudit and feedback Educational materials Educational meetings (patient and clinician) Local opinion leaders Reminders Effective Practice and Organisation of Care (EPOC). EPOC Taxonomy; Available at: https://epoc.cochrane.org/epoc-taxonomy

89 Effectiveness of Implementation StrategiesMost interventions have modest effects on outcomes 10% Overall absolute change in performance of 10% Knowledge translation in health care : moving from evidence to practice. (2013) Edited by Sharon E. Straus, Jacqueline Tetroe, Ian D. Graham. – 2nd ed.

90 Effects of Implementation StrategiesImplementation strategy Magnitude of effect (median absolute improvement of care) Source Printed educational material (n=45) 2.0% (IQR 0% to +11.0%) Gigure et al. 2012 Educational meetings (n=81) 6.0% (IQR +1.8% to +15.3%) Forsetlund et al. 2009 Education outreach (n=69) 5.6% (IQR +3.0% to +9.0%) O’Brien et al. 2007 Local opinion leaders (n=18) 12.0% (IQR +6.0% to +14.5%) Flodgren et al. 2011 Audit and feedback (n=82) 4.3% (IQR +0.5% to +16%) Ivers et al. 2012 Reminders (n=32) 11.2% (IQR +6.5% to +19.6%) Arditi et al. 2012

91 Implementation Strategies Cochrane EPOC on CADTH’s Rx for ChangeRX for Change is a searchable database containing current research evidence about interventions used to alter behaviors. https://www.cadth.ca/rx-change Implementation strategy Definition Effectiveness TDF domains Audit & feedback Any summary of clinical performance of health care over a specified period of time. May also include recommendations for clinical action. 45 reviews (8 high quality); effective for improving appropriate care and prescribing outcomes when used alone or combined with other implementation strategies. Behavioural regulation Intentions Beliefs about consequences Reinforcement Emotion Distribution of educational materials Distribution of published or printed recommendations for clinical care, including clinical practice guidelines, audio-visual materials and electronic publications. 60 reviews (13 high quality); effective for improving appropriate care outcomes. Knowledge Skills Beliefs about capabilities Goals Reminders Patient- or encounter-specific information, provided verbally, on paper or on a computer screen, which is designed or intended to prompt a health professional to recall information. Computer -aided decision support is included. 71 reviews (14 high quality); effective for improving appropriate care and prescribing outcomes Memory, attention and decision processes

92 Practice Change or Implementation Strategies?An organization wants to use audit and feedback to decrease physician prescribing of antipsychotics in long-term care. An organization uses reminder to encourage health care workers to get the flu vaccine. A community of practice is set up to support stroke best practices across the province. An organization aims to use educational materials to help doctors talk to patients about prostate cancer screening harms and benefits. Practice Change Implementation Strategies

93 Operationalizing the KTA

94 Select Implementation Strategies Using APRAISEREFER TO APRAISE Handout Appropriateness Practicability/Feasibility Risks Affordability Impartiality Sustainability Effectiveness and cost-effectiveness Adapted from: Michie S, Atkins L, West R: The behaviour change wheel: a guide to designing interventions. Great Britain: Silverback Pub; 2014.

95 ETP Mapping Worksheet #2Appropriateness* Practicability/ Feasibility* Risks* Affordability* Impartiality* Sustainability* Effectiveness/ Cost effectiveness* Implementation Strategy TDF Domain A P R I S E Strategy Selected? (Y/N) Local opinion leaders Beliefs about capabilities Beliefs about consequences Behavioural regulation Goals Intentions Memory, attention and decision processes Optimism Reinforcement Skills

96 ETP Mapping Worksheet #2: MOVEAppropriateness* Practicability/ Feasibility* Risks* Affordability* Impartiality* Sustainability* Effectiveness/ Cost effectiveness* Implementation Strategy TDF Domain A P R I S E Strategy Selected (Y/N) Local opinion leaders Beliefs about capabilities      Yes Beliefs about consequences Behavioural regulation Goals Intentions Memory, attention and decision processes Optimism Reinforcement Skills

97 Barriers to Practice Change vs. Barriers to ImplementationMOVE (Mobilization of Vulnerable Elders) Practice Change Implementation Strategies Assess mobility within 24 hours of admission Each patient mobilized at least 3 times a day Mobility is tailored to patient’s abilities Educational meetings Educational materials Local opinion leaders Reminders

98 Activity 6: Select Implementation StrategiesYou have 40 minutes to: Use ETP Mapping Worksheet #2, highlight all the domains you identified in ETP Mapping Worksheet #1 that relate to your barriers/facilitators. (5 minutes) Choose 3 implementation strategies and assess these using the APRAISE criteria. (20 minutes) Discuss selecting implementation strategies as a large group. (15minutes) 1 2 3

99 Activity 6: Discussion Did you experience any challenges when APRAISE-ing and selecting implementation strategies? Did assessing your identified implementation strategies change your thinking about implementation? If so, how?

100 The Three Stages of ExpertiseSource: Simon Wardley (http://blog.gardeviance.org/2008/04/three-stages-of-expertise.html)

101 KT Resources

102 ETP Mapping Worksheet #2Selected strategy; target audience TDF domains Barriers/facilitators Key messages/ action items Support components* Tools Training Technical assistance Quality assurance/ improvement

103 ETP Mapping Worksheet #2: MOVESelected strategy; target audience TDF domains specific to the identified domains Barriers/facilitators specific to the target audience Key messages/ action items Support components* specific to the selected strategy and target audience Tools Training Technical assistance Quality assurance/ improvement Classroom/ e- module education (educational meetings); hospital unit staff Knowledge Skills Social/professional role and identity - Beliefs about capabilities - Beliefs about consequences - Attitudes and beliefs about mobilization - Lack of knowledge about mobilization - Lack of knowledge about patient's mobility status - Fear of patient mobilization - Perceived lack of skills - Lack of clarity regarding roles and responsibilities -Lack of accountability i) Definition of the importance of early mobilization for seniors admitted to hospitals ii) Provide inter- professional strategies on how to mobilize patients in the hospital iii) Reinforce and discuss safety measures of mobilization practices/activities (i.e resources- algorithm) iv) Clarify and provide evidence (i.e., articles, portal. etc.) -MOVE Resource Manual -PowerPoint slides -Handouts - Education Coordinator - Physical space -IT logistics (if applicable) -MOVEs Portal Implementation documentation (i.e., content, reach, engagement)

104 MOVE Logic Model KEY ASSUMPTIONS:Activities target key barriers to early mobilization practices: knowledge, skills, social influences, decision making processes, intentions, goals, beliefs about capabilities, beliefs about consequences. Activities provide participants with capability, opportunity and motivation to change behaviour. Activities are appropriate to context

105 Behaviour change wheelSource: Michie, S., van Stralen, M.M., West, R. (2011). The behaviour change wheel: A new method for characterizing and designing behaviour change interventions. Implementation Science 6:42.

106 Consolidated Framework for Implementation Research (CFIR)Inner Setting Structural characteristics Networks and communications Culture Implementation climate Readiness for implementation Outer Setting Patient needs/resources Cosmopolitanism Peer pressure External policies/incentives Individual Characteristics Knowledge & beliefs Self-efficacy Stage of change Identification with organization Personal attributes Process Planning Engaging Executing Evaluating Intervention Characteristics Intervention source Evidence strength & quality Relative advantage Adaptability Trialability Complexity Design quality & packaging Cost Source: Damschroder, Laura J, et al. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science 4:50. doi: /

107 Rogers’ theory of diffusion of innovations

108

109 Interactive Systems FrameworkImplementation –Delivery System Supporting the Work –Support System Distilling the Information – Synthesis & Translation System General Capacity Use Innovation-Specific Capacity Use Synthesis Translation General Capacity Building Innovation-Specific Capacity Building Funding Macro Policy Climate Existing Research and Theory Source: Wandersman et. al (2008). Bridging the gap between prevention research and practice: The Interactive Systems Framework for dissemination and implementation. American Journal of Community Psychology, 41,

110 KT newsletters and resourcesCochrane EPOC group: Information about systematic reviews of educational, behavioural, financial, regulatory and organisational interventions designed to improve health professional practice. KT +: Information about current KT research https://plus.mcmaster.ca/KT/Default.aspx KT Canada newsletter: Information on upcoming KT events, resources, and research projects KTE CoP: Information on KTE practices and experience, building KTE capacity, KTE events, job opportunities and other related activities National Collaborating Centre for Methods and Tools (NCCMT): Information on KT methods and tools, networking opportunities, helpful links and resources Rx for Change: a searchable database containing current research evidence about intervention strategies used to alter behaviours of health technology prescribing, practice, and use. https://www.cadth.ca/rx-change

111 Learning Objectives RecapPresentation 1: Introduction to KT Define knowledge translation (KT) Identify differences between dissemination and implementation Presentation 2: Bringing research to practice Describe the knowledge-to-action model (KTA) Explain important aspects of designing an evidence-informed, theory-driven program (ETP) Presentation 3: Identify barriers & facilitators to change Describe how to assess barriers & facilitators to change Identify barriers and facilitators related to the practice change Presentation 4: Mapping barriers & facilitators Explain how to map barriers & facilitators to the Theoretical Domains Framework Describe COM-B Presentation 5: Implementation strategies Define implementation strategies Systematically select implementation strategies Stuart Miles/freedigitalphotos.net

112 Questions and comments

113 Activity #7: Learning Goals ReflectionsYou have 10 minutes to: Review your ‘Setting Learning Goals’ worksheet. (5 minutes) 1 2 Discuss as a large group. (5 minutes)

114 Workshop Evaluation and FeedbackPlease take a moment to complete the participant feedback form. Your feedback is important to us and will be used to inform improvements for future workshops.

115 Thank you!

116 Contact Information Julia E. Moore ext Melissa Courvoisier ext