Using Implementation Science to transform patient care (Knowledge to Action Cycle)

Collaborating for Better
Care Partnership
Master Class: ‘Using implementation
science to transform patient care’
1st September 2014
International Centre for Life
@AHSN_NENC
@JPresseau

Welcome and Introduction
Dr Jackie Gray
on behalf of
Ian Renwick
Chair, Collaborating for Better Care Partnership
(Chief Executive, Gateshead Health NHS
Foundation Trust)

Programme
09.00 Welcome
09.15 ‘Reducing variation of avoidable deaths through NIV interventions: a working case study’
Avril Lowery, Head of SafeCare, Gateshead Health NHS Foundation Trust
09.35 An overview of the ‘Knowledge to Action’ model of Implementation Science
Professor Jeremy Grimshaw
10.15 Refreshment Break
10.30 Implementation of Guidance Workshop
Workshop 1 - COPD - facilitated by Professor Jeremy Grimshaw
Workshop 2 - End of Life Care for Frail Elderly – facilitated by Dr Justin Presseau
12.00 Lunch
12.45 Implementation Workshop (Group Work and feedback)
Workshop 1 - COPD- facilitated by Professor Jeremy Grimshaw
Workshop 2 - End of Life Care for Frail Elderly – facilitated by Dr Justin Presseau
13.45 Workshop Feedback
14.15 Building organisational capacity to address clinical variation and raise standards of care
(including Q & A session)
14.45 Conclusions, Professor Jeremy Grimshaw
14.55 Next steps – action planning
15.00 Close

Reducing variation of avoidable
deaths through NIV interventions:
a working case study
Avril Lowery
Head of SafeCare,
Gateshead Health NHS Foundation Trust

Reducing variation of avoidable deaths
through NIV interventions: a working
case study’
Avril Lowery
Head of SafeCare
Gateshead Health NHS Foundation Trust

Background
 Chronic Obstructive Pulmonary Disease (COPD) is an overarching term used to
describe a number of conditions including chronic bronchitis, emphysema, chronic
obstructive airways disease and chronic airflow limitation.
 COPD affects 3 million people in the UK and remains the 5th most common cause
of death
 More than 9% of > 45year olds in Gateshead area will suffer from this condition
and 25 % will die from it.
 NICE Quality Standard 10 COPD Statement 11- People admitted to hospital with an
exacerbation of COPD with a persistent acidotic ventilatory failure are promptly
assessed for, and receive, non invasive ventilation delivered by appropriately
trained staff in a dedicated setting
 Prompt assessment and receipt of NIV should be defined as:
 assessment and receipt of NIV within 3 hours of presentation, and
 receipt of NIV within 1 hour of the decision being made to administer NIV.

Background
 Non-invasive ventilation (NIV) is a method of providing ventilatory support that
does not require the placement of an endotracheal tube. It is usually delivered via
a mask that covers the nose, but occasionally a full face mask covering the nose
and the mouth is required. NIV is most commonly used to treat acute respiratory
failure during exacerbations of COPD
 Large body of evidence illustrates that when used well, ward-based Non Invasive
Ventilation has many positive outcomes :
 Reduces mortality rate from AECOPD by 50% (i.e. reducing in-patient mortality
from 20 to 10% and number needed to treat to save 1 life is 10 – similar to
thrombolysis benefit in Acute myocardial infarction)
 Reduce critical care department (CCD) admissions for respiratory failure
secondary to AECOPD by 44%,
 Improves survival of these patients at three months and one year,
 Is cost effective via preventing CCD admissions,
 Reduced length of stay by average 4.5 days for NIV treated patients
 A need to improve delivery and timing of NIV for AECOPD across QEH

Patient pathway to NIV at QE Gateshead

Drivers for change at Gateshead
 NIV service set up in early 2000’s and unchanged since
 1,115 patients/year admitted with AECOPD.
 71 patients/year receive NIV for AECOPD
 National audit data would suggest that we should expect to treat
290 patients/year with NIV.
 Missing up to 19 patients/ month due to bed pressures &
requirement for NIV not being recognised in all appropriate
patients
 Limited to being delivered on respiratory ward or CCD
 Provision for only 3 patients at any one time
 Rarely beds immediately available on respiratory ward
 Sub-optimal initial treatment
 Delay in commencement of NIV
 Staffing – relied on ward nursing staff -24 beds

Drivers for Change
 Poor outcomes compared to national audit results:
 Mortality - for all NIV patients 40% in 2012 (31% nationally)
 Readmissions - e.g. 1 of the 4 patients who potentially could
have benefited from NIV in one month readmitted within 30
days of discharge
 LOS - patients treated on CCD have delays in transfer to
respiratory ward for ongoing care – slows discharge home
 Failure to meet target of NIV within 1 hour of failed maximal
medical therapy
• time to NIV for A&E admissions 5 hours
• Time to NIV for patients admitted to CCD from A&E median
of 2.5 hours

What did we do ?
 Weekly multidisciplinary ward base case review well
established - Hogan and NCEPOD outcome scores
introduced more recently
 Presentation of cases and key learning at M&M steering
group – supported business case for development of NIV
service
 Funding for 4 new IV machines (£300,000)
 4.8 WTE band 6 specialist nurses to provide 24/7 NIV
nurse led service (£300,000)
 Further non- recurrent funding £15,000 ( training &
education etc.)
 Some minor structural changes

Anticipated benefits of new nurse led
service
Early involvement in AECOPD across whole Trust
Optimisation of treatment ( preventing oxygen toxicity)
Early arterial blood gases
Commencement of NIV in A&E and any ward area
Prompt transfer to respiratory ward for ongoing care
Identification of patients who may benefit from critical
care involvement
Continued support and follow up for patients
established on NIV
Education and teaching throughout Trust
Potential reduced LOS = cost savings
 Timely, safe, streamlined patient pathway

Early results
 Early evidence that the service is working well for patients and
meeting national standards
 Service is now seeing and assessing 100 patients per month
 An average of 15 patients per month starting treatment with Non-
Invasive Ventilation - double the number of patients previously.
 This is being achieved within one hour in 100% of patients in line
with BTS guideline recommendations.
 Our data indicates that NIV is successful in 76% of patients, an
improvement on 66% in 2012.
 Our COPD patients treated with NIV now match trial mortality rates
(10% in-patient mortality) and all cause in-patient mortality
matches other large cohorts within the literature (33%, previously
being 40% in 2012).

Key enablers
Trust commitment to high quality care
Development of the Trust Morality and
Morbidity governance framework
Leadership and clinical ‘buy in’
Learning from multidisciplinary case reviews

Key challenges
Funding
Staffing
Clinical expertise and availability
Some resistance from non clinical to set up
costs

Expansion
of service
The
Future…
Growth of
team
Protected
NIV beds
Education
Widen
patient
criteria
&
Awareness

The future for improvement
Continue to develop and embed multidisciplinary
review of deaths
Ensure key learning is shared and developed into
action to improve patient care and pathways
Continue to develop systems for meaningful data
collection to provide assurance on the quality of
the care we provide our patients/ identify deficits
in service provision including the patient & staff
perspectives
Encourage collective efforts and team working to
enable effective and sustainable change

‘Knowledge to Action’ model
of Implementation Science
Reducing clinical variation
Raising standards of care
Senior Scientist, Ottawa Hospital Research Institute
Professor, Department of Medicine, University of Ottawa
Canada Research Chair in Health Knowledge Transfer
and Uptake

Background
• Consistent evidence of failure to implement evidence
based recommendations into clinical practice
– 30-40% patients do not get treatments of proven
effectiveness
– 20–25% patients get care that is not needed or
potentially harmful
• Suggests that implementation of evidence based
recommendations is fundamental challenge for
healthcare systems to optimise care, outcomes and
costs
Schuster, McGlynn, Brook (1998). Milbank Memorial Quarterly
Grol R (2001). Med Care

Approaches to implementation
ISLAGIATT
principle
‘It Seemed
Like A Good
Idea At The
Time’
Martin P Eccles

Implementation science
• Implementation is a human enterprise that can be
studied to understand and improve knowledge
translation approaches
• Implementation science is the scientific study of the
determinants, processes and outcomes of knowledge
translation.
• Goal is to develop a generalisable empirical and
theoretical basis to optimise implementation
activities

Developing implementation
science in the Academic Health
Science Network

Developing implementation
science in the Academic Health
Science Network
• To facilitate participants’ use of implementation
science theory & tools to address clinical
variation and raise standards of care
• To enable participants to explore their
organisational capability with respect to the
skills, knowledge, and resources required to
address clinical variation and raise standards of
care

Knowledge to Action Cycle
Knowledge to
action
Graham et al
(2006). Lost in
Knowledge
Translation. Time
for a Map? Journal
of Continuing
Education for
Health
Professionals

Knowledge to action cycle
Knowledge to
Action loop
From: Graham ID et al.
Lost in Knowledge
Translation: Time for a
Map? Journal of
Continuing Education in
the Health Professions,
2006

Knowledge to action cycle
Knowledge to
Action loop
From: Graham ID et al. Lost in
Knowledge Translation: Time
for a Map? Journal of
Continuing Education in the
Health Professions, 2006

Specifying behaviours of interest
• What is the behavior (or series of linked
behaviors) that you are trying to change?
• Who performs the behavior(s)? (potential
adopter)
• When and where does the potential adopter
perform the behavior?
• Are there obvious practical barriers to performing
the behavior?
• Is the behavior usually performed in stressful
circumstances? (potential for acts of omission)

Specifying behaviours of interest
• Often useful to specify target behaviours in
terms of:
– Action being performed
– Target at which the action is directed
– Context in which action is performed
– Time during which the action is performed.

Adapting knowledge to local
context
• May require additional data collection to
assess applicability of knowledge to local
context
• May require modification of recommended
actions based upon applicability, resources
and contextual issues

Designing interventions
Who needs to do
what differently?
Using a theoretical framework,
which barriers and enablers need to
be addressed?
Which intervention components could
overcome the modifiable barriers and
enhance the enablers?
How will we measure
behaviour change?

Who needs to do
what differently?
Using a theoretical framework,
which barriers and enablers need
to be addressed?
Which intervention components
could overcome the modifiable
barriers and enhance the enablers?
How will we measure
behaviour change?

Assessing barriers to implementation
• Formal assessment of context, likely barriers to
implementation
• Mixed methods
– Literature review
– Informal consultation
– Focus groups
– Surveys
• Needs interdisciplinary perspective

Barriers to implementation
• Structural (e.g. financial disincentives)
• Organisational (e.g. inappropriate skill mix, lack of
facilities or equipment)
• Peer group (e.g. local standards of care not in line
with desired practice)
• Individual (e.g. knowledge, attitudes, skills)
• Professional - patient interaction (e.g. problems with
information processing)

Theoretical
Domains
framework

Theoretical Domains Framework
Cane 2012
• 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

Behaviour Change Wheel
Ability
• Physical
• Psychological
Conscious and
automatic decision
processes
Environmental factors
• Physical
• Social

• Scheduled consequences
• Reward and threat
• Repetition and substitution
• Antecedents
• Associations
• Covert learning
• Natural consequences
• Health consequences
• Feedback and monitoring
• Goals and planning
• Social support
• Comparison of behaviour
• Self belief
• Comparison of outcomes
• Identity
• Shaping knowledge
• Regulation

• Graded tasks - Set easy
tasks, and increase difficulty
until target behavior is
performed.
• Behavioural
rehearsal/practice - Prompt
the person to rehearse and
repeat the behavior or
preparatory behaviors

Behaviour Change
Techniques
Theory /
Mediators
Modes of
Delivery

Usability studies
• Develop prototype intervention
• Test prototype in 5 to 8 subjects to review content and
format using ‘think aloud’ methodology. These sessions
will be audio recorded and the results transcribed and
analysed.
• In general a modest number of subjects are required
for usability testing (e.g. 8-9 subjects), and often 4 to 5
are necessary to identify 80% of the usability problems.
• Cycles of design, development and testing will be
completed until no further major revisions are needed.

Implementation of Guidance
Workshops:
Workshop 1 COPD – facilitated by Prof Jeremy
Grimshaw
Workshop 2 End of Life Care for Frail Elderly –
facilitated by Dr Justin Presseau

Building organisational capacity
to address clinical variation and
raise standards of care
(including Q & A session)

Conclusions

Next steps – action planning/
future Master Class

Promoting use of implementation
science beyond this session

How many of you are motivated to
use the tools we used today in
your own setting?

Motivation is rarely enough to
ensure change

Two simple but remarkably
effective strategies
• Clearly, concrete description of when, where,
and how you will perform an action
• Anticipated barriers to you performing that
action, and realistic solutions to circumvent
the barrier
• Demonstrated to help promote good
intentions being translated into action

Taking today’s insights forward into your
organisation: when, where & how
• Step 1: choose and write an action that you
want to take in your organisation to apply
what we have covered today.
• Step 2: Write:
– When you will do it (be specific)
– Where you will do it (be specific)
– How you will do it (be specific)
• 3 mins

The best laid plans…
• Now, imagine yourself enacting that when, when
and how plan.
• Can you envisage anything preventing you from
doing it?
• How would you feasibly address that barrier?
• Write:
– IF barrier __________________________ occurs
– THEN I WILL ________________________ to ensure I
can enact my plan

Closing remarks
Dr Jackie Gray
NEQOS

Get involved in the Work
Programme
• Sign up at the registration desk (in main foyer)
or
• Email Dr Jackie Gray jackie.gray5@nhs.net

Keep up to date with developments:
• Sign up for the e- bulletin at the registration desk
(if you haven’t already)
Resources will be available on:
You Tube - video will be uploaded (a link included in next e- bulletin)
Slide Share - slide deck will be uploaded (link included in next e-bulletin)
AHSN web site www.ahsn-nenc.org.uk
NEQOS web site www.neqos.nhs.uk/
Twitter - @AHSN_NENC

Additional materials from the
workshop sessions

WORKSHOP 1: COPD IMPLEMENTATION SCENARIO

Using Implementation Science to transform patient care (Knowledge to Action Cycle)

Recomendados

Recomendados

Mais conteúdo relacionado

Mais procurados

Mais procurados (20)

Semelhante a Using Implementation Science to transform patient care (Knowledge to Action Cycle)

Semelhante a Using Implementation Science to transform patient care (Knowledge to Action Cycle) (20)

Mais de NEQOS

Mais de NEQOS (19)

Último

Último (20)

Using Implementation Science to transform patient care (Knowledge to Action Cycle)