Translating Evidence into Practice. Sean M. Berenholtz, MD MHS FCCM Johns Hopkins University

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1 Translating Evidence into Practice Sean M. Berenholtz, MD MHS FCCM Johns Hopkins University 1

2 Questions: What comes to mind when you think about translating evidence into Practice? Who s role is it at your institution to translate evidence into practice? How often do you work with the quality improvement folks? Did you receive quality care during your last doctor visit?

3 Objectives: Identify the multi-level approaches to improve translating evidence into practice Discuss different strategies to improve patient care Review a model for large scale knowledge translation Identify gaps between best evidence and practice Applying the 4Es to creating reliable health care 3

4 RAND Study Confirms Continued Quality Gap Click to edit Master text styles Low back pain Second level Coronary artery disease Hypertension Third level Depression Fourth level Orthopedic conditions Condition Percentage of Recommended Care Received Colorectal cancer» Fifth level 53.9 Asthma 53.5 Benign prostatic hyperplasia 53.0 Hyperlipidemia 48.6 Diabetes mellitus 45.4 Headaches 45.2 Urinary tract infection 40.7 Hip fracture 22.8 Alcohol dependence 10.5 McGlynn et al, NEJM 2003; 348(26):

5 Approaches to Improve TRiP Approach Evidence-based medicine, Clinical practice guidelines, Decision aids Professional education and development Self-regulation, Recertification Assessment and accountability Feedback, Accreditation, Public reporting Patient-centered care, Patient involvement, Shared decision making Total quality management and continuous quality improvement, Restructuring processes, Quality systems, Breakthrough projects Assumptions Provision of best evidence and convincing information leads to optimal decision making and optimal care Bottom-up learning based on experiences in practice and individual learning needs leads to performance change Providing feedback on performance relative to peers, and public reporting of performance data motivates change in performance Patient autonomy and control over disease and care processes lead to better care and outcomes Improving care comes from changing the systems, not from changes in individuals Adopted from Grol R. JAMA 2001;286:

6 Click to edit Master text styles Second level Third level Fourth level» Fifth level Grol R. JAMA 2001;286:

7 Click to edit Master text styles Second level Third level Fourth level» Fifth level BMJ 2008;337:

8 Translating evidence into practice: A model for large scale knowledge translation Summarize the evidence Identify local barriers to implementation Measure performance Ensure all patient receive the intervention BMJ 2008;337:

9 Generalizable Central Line Associated Blood Stream Infection (CLABSI) Infect Control Hosp Epidemiol 2014;35(1): Ventilator Associated Pneumonia (VAP) Infect Control Hosp Epid. 2011;32(4): Venous Thromboembolism (VTE) Arch Surg. 2012;147(10): Colorectal Surgical Site Infections (SSI) J Am Coll Surg. 2012;215(2):

10 Central Line Associated Blood Stream Infections > 2 million central venous catheters placed in U.S. ICUs annually 16,000 CLABSI in U.S. ICUs annually Mortality: 18% (0-35%) Annual deaths: 500-4,000 Cost per episode: $28,690-$56,000 Annual cost: $60 - $460 million CDC. MMWR 2002; Heiselman JAMA 1994; Dimick Arch Surg

11 Gap Between Best Evidence and Practice Knowledge awareness or familiarity (n=77) Attitudes agreement (n=33) self-efficacy (n=19) outcome expectancy (n=8) inertia of previous practice (n=14) Behavior external barriers (n=34) Cabana et al. JAMA 1999

12 Central Line Associated Blood Stream Infection (CLABSI) Prevention Remove Unnecessary Lines Wash Hands Prior to Procedure Use Maximal Barrier Precautions Clean Skin with Chlorhexidine Avoid Femoral Lines 12

13 Standardize Care ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY 13

14 Engage Educate Creating Reliable Health Care Executive Leaders Click to edit Master text styles How Does This Make the World a Better Place? Second level Third level Fourth level» Fifth level Team Leaders What Do We Need to Do? Staff Execute How can we do it with my resources and culture? Evaluate How Do We Know We Made a Difference? Health Services Research

16 Michigan Keystone ICU CLABSI Rate: N Engl J Med 2006;355: ; BMJ 2010;340:c

17 National Efforts On the CUSP:Stop BSI Program 1,071 ICUs in 45 states 43% CLABSI reduction Number of ICUs that achieved CLABSI rate of ZERO, more than doubled Infect Control Hosp Epidemiol 2014 Jan;35(1):

18 Lessons Learned Harm is preventable Many complications, including HAIs, are preventable Should be viewed as defect Focus on systems -- Not individuals Far more complex than a checklist Engage frontline staff to identify and fix local defects ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY 18

19 Key Concepts: Technical and Adaptive Work Technical Work Evidence-based interventions Sweet Spot Adaptive Work Local culture

20 How Will We Get There? TECHNICAL WORK Click to edit Master text styles Second level Work that we know we should do, like appropriate antibiotic dosing Third level and skin preparation Fourth level» Fifth level Work that lends itself to standardization (e.g., checklists and protocols) ADAPTIVE WORK The intangible components of work, like ensuring team members speak up with concerns and hold each other accountable Work that shapes the attitudes, beliefs, and values of clinicians, so they consistently perform tasks the way they know they should Evidence-based interventions Safety culture, including teamwork

Learning, Development, and Capacity Target: People aiming for a career in safety- quality work - Graduate degrees - Career development awards Target: Healthcare leaders /managers with

21 Learning, Development, and Capacity Target: People aiming for a career in safety- quality work - Graduate degrees - Career development awards Target: Healthcare leaders /managers with responsibility for improving safety-quality - Patient Safety Certificate - Safety fellows Target: All healthcare professionals - Medical, nursing, and other healthcare professions students - Residents, fellows 21

AI Patient Safety Training Online Patient Safety Certificate 13 modules, 18 hours Patient Safety Certificate Program 24 modules, 5 consecutive days Patient Safety Fellowship 6 months, didactic,

22 AI Patient Safety Training Online Patient Safety Certificate 13 modules, 18 hours Patient Safety Certificate Program 24 modules, 5 consecutive days Patient Safety Fellowship 6 months, didactic, mentorship Analytics Leadership in Patient Safety 12 months, didactic, mentorship For more, visit ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY 22

23 COMPREHENSIVE UNIT-BASED SAFETY PROGRAM (CUSP) A practical approach to tap into the wisdom of frontline staff and improve teamwork and safety culture 23

24 CUSP Pre-work Comprehensive Unit-based Safety Program Start in one unit and then spread Imperative for frontline staff to be involved Build strong partnerships: Infection prevention staff Hospital quality and safety leaders Nurse educators Physician leaders ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY 24

25 CUSP Objectives Comprehensive Unit-based Safety Program 1. Educate staff on science of safety 2. Identify defects 3. Partner with a senior executive 4. Learn from defects 5. Improve teamwork and communication Jt Comm J Qual Patient Saf 2010;36: Resources: 25

26 Statewide Michigan CUSP ICU Results "Needs Improvement Needs Improvement: Less than 60% of respondents reporting good safety or teamwork climate Statewide in % needed improvement, down to 22-23% in % 82% 23% 22% Safety Climate Teamwork Climate Before After J Critical Care 2008;23: Crit Care Med 2011;39(5):1-6 26

27 Best Way Forward Harm is preventable Many complications, including HAIs, are preventable; Should be viewed as defect Informed by science Technical and adaptive teamwork Led by clinicians and supported by management Tap into wisdom of frontline staff Need to build capacity ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY 27

28 Engagement: Small group discussions from pre-work Results from discussions with quality improvement folks at your institution Ask: What quality driven organizational projects are being addressed? Are there financial implications for these projects? (High level projects could be aligned with your organization s strategic priorities, mission, vision, and external reporting requirements for quality measures.) What quality metrics are being used? Think about how you can CME/CPD get involved? Ask the organizational leaders is there a way they can envision how they think the CME/CPD office can get involved. 28

Translating Evidence to Safer Care

Translating Evidence to Safer Care Patient Safety Research Introductory Course Session 7 Albert W Wu, MD, MPH Former Senior Adviser, WHO Professor of Health Policy & Management, Johns Hopkins Bloomberg