Promoting Evidence-Informed Decision Making. Maureen Dobbins, RN, PhD

Transcription

1 Promoting Evidence-Informed Decision Making Maureen Dobbins, RN, PhD

2 Objectives Historical perspective What is evidence Evidence-informed decision making Challenges in changing practice Sources of effective nursing practice Theoretical models Steps to change

3 A Knowledge Transfer Story.circa 1747 Time Elapsed from Lancaster to Adoption: 264 years Vasco da Gama Rounds Cape of Good Hope to find sea route to India. Of the 160 crew, 100 die of scurvy Captain Lancaster sails with 4 ships; Crew #1 given 3tsps lemon juice daily Dr. James Lind conducts random trials of six treatments for scorbutic sailors British Navy orders citrus fruit in diet for sailors British Board of Trade orders citrus on merchant marine vessels

4 Evolving Story Consistent evidence of failure to translate research findings 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 Schuster, McGlynn, Brook (1998). Milbank Memorial Quarterly Grol R (2001). Med Care

5 Health Care Decision-Making Clinical state, setting, and circumstances Patient preferences and actions Clinical Expertise Clinical Expertise Research evidence Health care resources

6 Evidence: What is it? How is evidence defined differently by: Clinicians? Decision-makers? Researchers

7 Single Study Nature of Evidence Systematic Review Systematic consolidation of the literature on a specific topic System Practice guidelines, clinical pathways or evidence-based textbook summaries that integrate evidence-based information about specific healthcare or social problems and provide regular updating

8 Forms of Evidence Context-free research evidence Context-sensitive research evidence Colloquial evidence Expert & professional opinion Political judgment, values, habits & traditions Lomas et al (2005)

9 Evidence-Informed Decision Making Interest in applying research spreading from clinical settings to policy domains In policy, the purity of research is contaminated by values, interests, ideology

10 Challenges in Changing Practice Time constraints in an Organization Limited access to research evidence Limited training in information seeking and critical appraisal skills Lack of organizational support

11 RNAO Best Practice Guidelines

12 Knowledge Transfer and Exchange Framework Knowledge Persuasion Decision Implementation Confirmation Knowledge transfer strategies Evidence-informed Decision-making Knowledge Uptake Outcomes Adopt Reject Dissemination strategies Innovation characteristics Decision-making efforts Organizational characteristics Environmental characteristics Individual characteristics Implement ation strategies Pt outcomes resource allocation expenditures organizational performance (Dobbins et al, 2002)

13 A Framework for Knowledge Transfer and Uptake Knowledge Persuasion Decision Implementation Confirmation Research Dissemination Evidence-informed Decision-making Research Utilization Outcomes academic detailing outreach audit & feedback CME workshops conferences opinion leaders knowledge brokers (Dobbins, 2002)

14 A Framework for Knowledge Transfer and Uptake Knowledge Persuasion Decision Implementation Confirmation Research Dissemination Evidence-informed Decision-making Research Utilization Outcomes KT strategies Innovation characteristics Organizational characteristics Individual characteristics Environmental characteristics

15 A Framework for Knowledge Transfer and Uptake Knowledge Persuasion Decision Implementation Confirmation Research Dissemination Evidence-informed Decision-making Research Utilization Outcomes Dissemination strategies Organizational characteristics Innovation characteristics Individual characteristics type of decision values/beliefs evidence culture decision-making style type of innovation Environmental characteristics

16 Setting the Stage Identification of high quality research Involvement of appropriate stakeholders Assessment of environmental readiness CHSRF Self-assessment tool helps determine how well the organization uses research and where there is room for improvement

17 Setting the Stage Use of evidence-based implementation strategies that complement the environmental readiness assessment Evaluation of the implementation Consideration of resource implications to carry out activities

18 Toolkit for Best Practice Guideline Implementation Resources Identify CPG Stakeholders Environmental Readiness Implementation Strategies Evaluation

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20 KNOWLEDGE PHASE Step 1: Select a Best Practice Guideline to Implement Systematically search for all available best practice guidelines Literature review Internet Organizations/Associations Review each best practice guideline AGREE Instrument Select a best practice guideline Identify recommendations that can be implemented

21 KNOWLEDGE PHASE Step 1: Select a Guideline to Implement Grades (or strength) of recommendation: confident that adherence to a recommendation will do more good than harm Example (Canadian Task Force on Preventive Health Care): A: Good evidence supporting recommendation B: Fair evidence C: Insufficient evidence D: Fair evidence that to exclude recommendation E: Good evidence to support exclusion

22 PERSUASION PHASE Step 2: Identify Factors Likely to Influence Adoption of New Practice Characteristics of: Innovation Organization Environment Individual

23 PERSUASION PHASE Step 2: Identify Factors Likely to Influence Adoption of New Practice Innovation: Relative advantage Compatibility Complexity Trialability Observability

24 PERSUASION PHASE Step 2: Identify Factors Likely to Influence Adoption of New Practice Organization: High functional differentiation Culture that values use of research evidence Effective communication systems Decentralized decision making Managerial support for change Adequate resources

25 PERSUASION PHASE Step 2: Identify Factors Likely to Influence Adoption of New Practice Individual: Perceived relevance of research to decisionmaking Extent of decision-making authority Time to review literature Time to implement innovation Critical appraisal skills

26 PERSUASION PHASE Step 2: Identify Factors Likely to Influence Adoption of New Practice Assess readiness for adoption of innovation based on characteristics of innovation, organization, environment, individual Proceed with implementation of innovation or address barriers first

27 Identify Resources Create a budget to finance implementation & evaluation of BPG Consider strategies to persuade administration to contribute required resources to effectively implement and evaluate the BPG in your organization

28 DECISION PHASE Step 3: Identify Stakeholders to be Involved in Decision to Adopt Innovation Identify key stakeholders Analyze their interests Determine the level of support and influence related to your plans within your organization Develop strategies to engage key stakeholder involvement

29 IMPLEMENTATION PHASE Identify Strategies to Disseminate Information about New Practice Generally Effective Education outreach visits: trained person meets 1:1 with professional Reminders: prompts Interactive educational meetings/workshops Multifaceted intervention including > 2 of: audit & feedback: written/verbal summary of performance Reminders Local consensus process: inclusion of participating professionals in discussions to ensure they agree with approach

30 IMPLEMENTATION PHASE Identify Strategies to Disseminate Information about New Practice Sometimes Effective Audit and feedback Local opinion leaders: use of respected colleagues as educationally influential Local consensus process Patient mediated interventions: aimed at changing performance of professionals through interactions with, or information provided to, patients

31 IMPLEMENTATION PHASE Identify Strategies to Disseminate Information about New Practice Little or No Effect Educational materials: distribution of published or printed recommendations Didactic educational meetings/conferences/workshops: lectures

32 CONFIRMATION PHASE Step 5: Evaluate Success of Implementation Design an evaluation plan that outlines: Anticipated goal(s) of BPG implementation Target group (e.g. social workers, clients) Short and long term objectives

33 CONFIRMATION PHASE Step 5: Evaluate Success of BPG Implementation Structure evaluation Availability of physical & human resources to implement new service (e.g., number and qualifications of staff) Process evaluation Examination of whether and how new practice has been implemented (e.g., client knowledge level) Outcome evaluation Examination of whether innovation has had its intended effect (e.g., physical, psychological, social outcomes; access to services, satisfaction with services)

34 Key Questions Did the search for evidence identify the most highly synthesized current information What characteristics will influence adoption Who are the key stakeholders What factors need to be considered to make an evidence-informed decision What strategies will promote behavioral change What indicators should I use to evaluate success

35 Organizational Context How do you assist your staff/colleagues to become critical consumers of information sources and maintain critical appraisal skills?

36 Organizational Context (cont d) What mechanisms would you put in place to assist staff/colleagues to identify, access, assess, interpret, and apply research evidence within the local context?

37 Complete an Action Plan Identify all activities and actions that need to be taken Identify individuals, groups or committees to carry out activities Develop critical path with specific timelines Communicate plan to relevant stakeholders Monitor progress and develop contingency plans

38 Considerations Design plan to be fluid or adaptable for unexpected situations Involve key stakeholders throughout planning exercise Note, communicate and celebrate all milestones in action plan Identify committees, groups or individuals who will ensure ongoing sustainability of the new practice