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• Ken N. Kuo• Chair Professor• Cochrane Taiwan, Taipei Medical University
• 國際醫學教育研討會 June 30, 2018
Quality Improvement Through
Knowledge Translation
透過知識轉譯改善品質
Outline
2
1. KT and QI2. Definitions and characteristics of KT 3. KT Models 4. Barriers and effective strategies of KT5. Health Policy6. Examples sharing and discussion7. Conclusion
Outline
3
• KT and QI• Definitions and characteristics of KT • KT Models • Barriers and effective strategies of KT• Health Policy• Examples sharing and discussion• Conclusion
Quality improvement (QI)改善品質
4
QI consists of systematic and continuous actions that lead to improvement in healthcare delivery systems and health status of targeted populations.
There are several ways to approach the QI ProcessPDCA cycle Plan‐Do‐Check‐Act
https://www.sketchbubble.com/en/powerpoint‐pdca‐cycle.html
品質改善包括系統性及連續性的運作,使健康照護系統以及民眾健康狀態的進步。
有幾個方法能導致品質改善→PDSA Cycle
Knowledge translation (KT) 知識轉譯
5https://www.canchild.ca/en/research‐in‐practice/knowledge‐translation‐exchange
A method for moving evidence‐base knowledge into stakeholder action
KT process involves two essential phases:knowledge creation
知識創造
knowledge application知識應用
一個把實證的知識應用到權益關係人的方法
KT and QI
6
KT and QI shared the same concept with different approach. They can making better clinical practice, and enhance quality of healthcare.
Outline
7
• KT and QI• Definitions and characteristics of KT • KT Models • Barriers and effective strategies of KT• Health Policy• Examples sharing and discussion• Conclusion
8
Knowledge Translation
“A dynamic and iterative process that includes synthesis, dissemination, exchange and ethically‐sound application of knowledge to improve the health, provide more effective health services and products as well as strengthen the health care system.“一個有動態及重複的步驟,包括綜合、傳播、互相交換,以及符合倫理的應用知識以增進健康,提供有效率的健康照護以及成果,並且加強健康照護系統。
Straus, S., Tetroe, J., & Graham, I. D. (2013). Knowledge translation in health care: moving from evidence to practice: John Wiley & Sons.
Knowledge Creation (Evidence)‐1 Consists of 3 phases: (1) knowledge inquiry, (2) knowledge synthesis, and (3)
knowledge tools/products.
包括 (1)知識查詢 (2)知識合成 (3) 知識使用工具/成果
Knowledge creation was conceptualized as an inverted funnel, with a vast number of knowledge pieces present in the knowledge inquiry process in the beginning.
知識創造的概念就像一個反過來的漏斗,大量的知識從知識查詢過濾
Those pieces are then reduced in number through knowledge syntheses and, finally, to an even a smaller number of tools or products to facilitate implementation of the knowledge.
用知識合成的過程,萃取出少量的研究證據,以促進知識轉譯
9Straus, S., Tetroe, J., & Graham, I. D. (2013). Knowledge translation in health care: moving from evidence to practice: John Wiley & Sons.
Knowledge Creation (Evidence)‐2 The needs of potential knowledge users can be incorporated into each
phase of knowledge creation
對潛在的知識使用者的需求可結合在每一部分的知識建構
量身訂做:tailoring the research questions to address the problems identified by the users 鑑別使用者的問題,量身訂做研究問題
customizing the message for different intended users對不同使用者量身訂做訊息
customizing the method of dissemination to better reach them量身訂做使用者傳達訊息的方法
10Straus, S., Tetroe, J., & Graham, I. D. (2013). Knowledge translation in health care: moving from evidence to practice: John Wiley & Sons.
Glasziou P, Haynes B. (2005) The paths from research to improved health outcomes. Evid Based Nurs. 8(2), 36-8.
Paul Glasziou Brian Haynes
Knowledge Creation
(Evidence)
KnowledgeApplication
from bench to bed (“B2B” : “5S” , “7A”)
11
KT is the process of putting knowledge into action.
A knowledge creation "funnel" conveys the idea that knowledge needs to be increasingly distilled before it is ready for application.
The action part of the process can be thought of as a cycle leading to implementation or application of knowledge.
In contrast to the knowledge funnel, the action cycle represents the activities that may be needed for knowledge application.
12
Knowledge Translation
Straus, S., Tetroe, J., & Graham, I. D. (2013). Knowledge translation in health care: moving from evidence to practice: John Wiley & Sons.
知識轉譯是把知識轉化為行動
知識創建漏斗是把需要的知識淨化,準備變成行動
經過循環導致採用知識的行動
和知識漏斗不同的是行動循環代表知識應用的行動
Knowledge application Graham et al. (2006) conceptualized the action cycle as a
dynamic process in which all phases in the cycle can influence one another and can also be influenced by the knowledge creation process. Identifying the knowledge‐to‐action gaps Adapting knowledge to local context Assessing barriers/ facilitators to knowledge use Selecting, tailoring, implementing interventions Monitoring knowledge use Evaluating outcomes Sustaining knowledge use
13Straus, S., Tetroe, J., & Graham, I. D. (2013). Knowledge translation in health care: moving from evidence to practice: John Wiley & Sons.
14
15
2015.09.02. Cochrane Taiwan 成立
Cochrane Australia
Cochrane China
Cochrane Hong Kong
Cochrane Indonesia
Iran Cochrane Japan
Cochrane Korea
Cochrane Malaysia
Cochrane Thailand
Cochrane Singapore
Cochrane New Zealand
Cochrane: Centres, Associates Centres (Asia‐Pacific)
Cochrane South Asia
Taipei Medical University
16
http://taiwan.cochrane.org/
17
Journal Club
Overcome the Gaps between knowledge & practice
GAP?
Outline
18
• KT and QI• Definitions and characteristics of KT • KT Models • Barriers and effective strategies of KT• Health Policy• Examples sharing and discussion• Conclusion
實證知識要經過轉譯的過程,才能順利應用於臨床上
Knowledge Translation closing the know‐do gap知識轉譯(knowledge translation)是一個包含對知識的合成、傳播、交換,以及符合倫理應用之反覆的動態流程。
Straus, S., Tetroe, J., & Graham, I. D. (2013). Knowledge translation in health care: moving from evidence to practice: John Wiley & Sons.
NIH RoadmapResearch to Translation ‐ 知識轉譯
Westfall, Mold and Fagnan, JAMA, 2007; 297(4):403‐406
• The current NIH Roadmap for Medical Research includes 2 major research laboratories (bench and bedside) and 2 translational steps (T1 and T2).
• Proposed expansion of the NIH Roadmap (blue) includes an additional research laboratory (Practice‐based Research) and translational step (T3) to improve incorporation of research discoveries into day‐to‐day clinical care.
CIHR Model of Knowledge Translation
21
• KT1: Defining research questions and methodologies
• KT2: Conducting research (as in the case of participatory research)
• KT3: Publishing research findings in plain language and accessible formats
• KT4: Placing research findings in the context of other knowledge and sociocultural norms
• KT5: Making decisions and taking action informed by research findings
• KT6: Influencing subsequent rounds of research based on the impacts of knowledge use
Source: Canadian Institutes of Health Research Knowledge Translation [KT] within the Research Cycle Chart. Ottawa: Canadian Institutes of Health Research, 2007.
22Chen, Huang, Kuo, Tam: Evidence‐based health care: A roadmap for knowledge translation, J Chin Med Assoc. 2017 Dec..
Outline
23
• KT and QI• Definitions and characteristics of KT • KT Models • Barriers and effective strategies of KT• Health Policy• Examples sharing and discussion• Conclusion
Barriers of KT
24
Heavy workload, no time Inability to access or appraise the evidence (Language barrier) Organization culture, resistance to change Lack of authority/ confidence to make change Lack of Leader/ peer/ team workers’ support Lack of education and training Lack of consensus of SOP SOP is too complex and content is confusing Lack computer‐assisted devices (reminders) Lack of resources to implementation Patients and caregivers have different opinions
Abrahamson et al., 2012; Asadoorian, Hearson, Satyanarayana, & Ursel, 2010; Brazil, Cloutier, Tennen, Bailit, & Higgins, 2008; Forsman et al., 2012; Gaddis, Greenwald, & Huckson, 2007; Goossens, Bossuyt, & de Haan, 2008; Grol & Wensing, 2004; Hutchinson & Johnston, 2004; Koh et al., 2008; Lyons et al., 2005; Pogorzelska & Larson, 2008; Sinuff et al., 2007
Effective strategies of KT
25
Leadership of organization Use of local opinion leaders Local consensus processes Tailored, evidence‐based, multifaceted, patient‐
mediated Interventions Peer support and collaboration Interactive educational meetings Integrate into SOP or information system Manual or computerized reminders Audit and Feedback
Abrahamson et al., 201; Gagnon, 2011; Goossens et al., 2008; Ho et al., 2004; Hutchinson & Johnston, 2004; Pentland et al., 2011; Stenberg & Wann‐Hansson, 2011
Outline
26
• KT and QI• Definitions and characteristics of KT • KT Models • Barriers and effective strategies of KT• Health Policy• Examples sharing and discussion• Conclusion
27
1) 多學科參與的價值和重要性2) 需要廣大的實證基礎來做借鑒3) 研究和政策需要有循環關係4) 政策實施需要在地化5) 權益關係人參與的效益6) 有政府的支持
Transforming and scaling up health professionals’ education and training: WHO guidelines 2013
The process of developing Evidence‐based Clinical Practice Guidelines
30
Knowledge Creation
(Evidence)
KnowledgeApplication
Evidence‐based Clinical Practice Guidelines
31
台灣氣喘臨床照護指引
Knowledge Translation
T1:Composition of knowledge
Evidence‐based
guidelines
Electronic record
databank
Systemic Review
T2: application of knowledge
Precision Medicine
Shared decision making
Health policy
Deliberative dialogues as a mechanism for knowledge translation and exchange in health systems decision‐making
33
The key features described in the model are: 1. an appropriate (i.e., conducive to the particular dialogue)
meeting environment; 2. an appropriate mix of participants; and, 3. an appropriate use of research evidence.
These features combine to create three types of intended effects: 1. short‐term individual‐level; 2. medium‐term community/organizational‐level; 3. long‐term system‐level.
協商及交換意見做為知識轉譯及健康照護的機制
重要的特徵: 1.適當的開會環境(有利用特別的協商); 2. 適當的參與者;及, 3. 適當的利用研究的證據.
以上三個特徵產生預期的效果: 1. 短期 個別效果; 2. 中期 社群/組織效果; 3. 長期 系統的效果.
Outline
34
• KT and QI• Definitions and characteristics of KT • KT Models • Barriers and effective strategies of KT• Health Policy• Examples sharing and discussion• Conclusion
From Evidence to Practice
Bed rest
Successful model of knowledge translationYear Clinical Topics of Gold Medal in EBM competition Hospital
2016 以實證知識轉譯架構及應用資訊策略預防住院病人跌倒 萬芳醫院
2015 導入實證醫學探討吞水試驗對腦中風吞嚥困難病人之診斷精確度
高雄長庚醫院
2014 應用MALDI‐TOF質譜儀優化臨床細菌鑑定報告之時效及準確度
林口長庚醫院
2013 成人依臨床症狀更換周邊靜脈導管是否會增加靜脈炎發生率
臺北榮總
2012 實踐實證為基礎的重症病人壓力性潰瘍建議 新光醫院
2011 哺乳婦女使用乳汁或羊毛脂對於降低乳頭破皮及疼痛是否有差異
馬偕淡水分院
2010 比較Terbinafine和Griseofulvin對於兒童頭癬的治療效果 馬偕醫院
2009 全腹膜外內視鏡腹股溝疝氣修補手術之人工網膜固定改善專案
北醫附醫
Resource: http://www.tjcha.org.tw/
Outline
38
• KT and QI• Definitions and characteristics of KT • KT Models • Barriers and effective strategies of KT• Health Policy• Examples sharing and discussion• Conclusion
39
Ask• Key questions
Acquire• Del Duplicates• Find Full text
Appraisal• Data extraction• Analysis• SR/ MA
Apply & AuditQuality improvement!
• Evidence-based Guideline• AI, Informatics• Clinical Data bank• Big data analysis
ServiceTeachingResearchInternational
Integrate all resources for knowledge translation
Modify from “Straus et al.: Evidence-based medicine, Elsevier Ltd., 2005”, Brian Haynes, R Evid Based Med 2006;11:162-164
Systems
Summaries
Synopses
Syntheses
Studies
Aware Accepted Applicable Able Acted on Agreed Adhered to Unsound Research
Sound Research
5S
From Evidence to Practice
Global evidence
Local implementation
醫療 Healthcare 4.0
系統性文獻回顧 Systematic Review
• 醫療科技評估Health Technology Assessment(HTA)
• 醫病共同決定Shared Decision Making
• 臨床診療指引Clinical Practice Guideline
• 低效益醫療Low-value healthcare
• 醫療明智選擇Choosing Wisely
實證健康照護延伸─病人參與及跨領域研究
44
Thank you!