12/9/18. Implementing Meaningful Projects to Enhance EBP in your Clinic. Objectives. Overview

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1 Implementing Meaningful Projects to Enhance EBP in your Clinic Wendy Romney, PT, DPT, PhD, NCS Jenni Moore, PT, DHS, NCS Julie Tilson, PT, DPT, MS Susan Perry, PT, DPT Judith E Deutsch, PT, PhD, FAPTA Hallie Zeleznik, PT, DPT, NCS Objectives Explore quality improvement (QI) and knowledge translation (KT) practice and research in physical therapy Describe strategies to plan, implement and evaluate QI/KT projects Develop QI/KT action plans Overview Define and review the history of QI and KT research (10 minutes) Review strategies to implement QI and KT projects (10 minutes) Project development and feedback by presenters (1 hour) Highlight key points from project and new directions (20 minutes) Questions and Answers 1

2 Quality Improvement Quality A direct correlation between the level of improved health services and the desired health outcomes of individuals and populations (IOM) Linked to service delivery and underlying systems of care To change performance (i.e.: improve quality), the healthcare organizations systems of care need to change Quality of Care Gap (McGlynn, 2003) Evidence-Based Best Practice Recommendations vs. Actual Care Delivered 54.9% of the time the recommended care was delivered 2

3 Systems and Processes Patient Focused Team Oriented Data Focused Need to understand underlying processes Care should meet the needs and expectations of the patient Accessible, evidence-based, safe, coordinate and appropriate Processes in healthcare are complex Team pulls in the knowledge, skills, experience and perspectives from different individuals What we think is happening vs. what is really happening Establish baselines, monitor for changes, compare performance across sites/sytstems 4 Key Principles of QI The Model for Improvement & Plan Do Study Act Act What are we trying to accomplish? Standardize the improvement or determine a new theory Establish future plans Plan Organize a team Examine current processes Identify solutions Develop the improvement theory How will we know that a change is an improvement? What changes can we make that will result in improvement? Study Use the data to study the results Were you successful in the change and did outcomes improve> Do Test the theory for improvement Associates in Process Improvement Quality Improvement Literature in Rehabilitation Adherence to protocols and reduced costs for patients with LBP (Stevens, 2015) Promote a culture of mobility in an ICU setting (Harris, 2014) Use of registry for outcome measure reporting (Meerhoff, 2017) Opportunity for QI research/publication growth in our field (Jesus, 2018) 3

4 Knowledge Translation Knowledge Translation A dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve health, provide more effective health services and products and strengthen the health care system Canadian Institute of Health Research, 2005 KT Interventions Strategies to promote awareness and implementation of new knowledge 4

5 QI and KT Knowledge Translation Apply Best Evidence Systematic Reduce Unwarranted Variation Detailed Barrier Assessment Intervention Mapping Improve Patient Outcomes Reduce Healthcare Costs Assessment of Outcomes Knowledge Translation Interventions Theoretically Informed (Eccles, 2005; Field, 2014; Hudon, 2014; Kitson, 2008; Sudsawad, 2007) Locally tailored (Duncan & Murray, 2012) Active (Grimshaw, 2012; Jones, 2014; Menon, 2009) Multi-modal (Grimshaw, 2012; Jones, 2014; Menon, 2009) (Graham, 2006) Knowledge-to-Action Framework: (Graham, 2006) 5

6 Barrier Assessment (Duncan and Murray 2012) Patients Characteristics (Salbach 2011, Pattison 2015) Physical Therapists/Healthcare Providers Knowledge, Education and Perceived value Organization Support Practice Considerations Time Culture Setting External Environment Intervention Mapping (EPOC) Education Audit and feedback (Colquhoun, 2017) Adherence goal Local opinion leaders (Russell 2010, Perry 2014, Schreiber 2015, Romney 2018, Moore 2018) Knowledge brokers, facilitators, champions Group consensus and engagement (Leehman, 2014) Organizational Support (CFIR) (Damschroder, et al 2009) Environmental Change (Michie, 2008) Reminders (Michie, 2008) Effectiveness of KT Interventions (Grimshaw, 2012) 14% 12% 10% 8% 6% 4% 2% 0% Printed Educational Material Educational Educational Local Opinion Meetings Outreach Leaders Median Absolute Improvement Audit and Feedback 6

7 Outcomes (Straus, 2013) Mixed methods Quantitative: survey, chart audit, case vignettes Qualitative: focus group and individual interviews Physical therapists Patient Organization KT Interventions in Physical Therapy General EBP (Christensen 2017; Lizarondo 2012; Moore 2018; Schreiber 2009; Tilson 2014) Implementation of CPG (LBP, Stroke, Neck Pain) (Bekkering, 2005; Bernhardsson, 2014; Maas, 2015; Rebbeck, 2016; Salbach 2017; Willems 2016) Use of standardized assessments (Colquhoun 2017; Kall 2016; Meerhoff 2017) Specific interventions: Fall prevention (Brown, 2005) Stroke (Connell 2016; Levac 2016; Nanninga 2015; Perry, 2014) Parkinson s disease (Leavy, 2017) Project Development Project ideas and discussion 7

8 Project Ideas Implementation of Clinical Practice Guidelines Stroke Low Back Pain Neck Pain Fall Prevention Early Mobility in the ICU Outcome Measure Contact Information Wendy Romney Jenni Moore Julie Tilson Susan Perry Judy Deutsch Hallie Zeleznik 8

9 Implementing Meaningful Projects to Enhance EBP in your Clinic -- Worksheet What is the goal of your project, i.e., what kind of behavior change would you like to see (best determined by local consensus with buy-in at multiple levels)? What are the anticipated barriers to this behavior change? Why hasn t this change already occurred? (e.g., patient characteristics, provider knowledge/education/perceived value, organizational support, practice considerations such as time, culture, setting, external environment, other?) Develop an intervention plan that considers anticipated barriers. Include a timeline. How will you monitor behavior change? How will you evaluate the impact of this behavior change? What is your plan for sustainability?

10 References McGlynn EA. An evidence-based national quality measurement and reporting system. Med Care. 2003;41(1 Suppl):I Stevans JM, Bise CG, McGee JC, Miller DL, Rockar P, Jr., Delitto A. Evidence-based practice implementation: case report of the evolution of a quality improvement program in a multicenter physical therapy organization. Phys Ther. 2015;95(4): Harris CL, Shahid S. Physical therapy-driven quality improvement to promote early mobility in the intensive care unit. Proc (Bayl Univ Med Cent). 2014;27(3): Jesus TS, Papadimitriou C, Pinho CS, Hoenig H. Key Characteristics of Rehabilitation Quality Improvement Publications: Scoping Review From 2010 to Arch Phys Med Rehabil. 2018;99(6): e Canadian Institute of Health Research. About Knowledge Translation. 2005; Accessed May 30, Eccles M, Grimshaw J, Walker A, Johnston M, Pitts N. Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings. Journal of clinical epidemiology. 2005;58(2): Field B, Booth A, Ilott I, Gerrish K. Using the Knowledge to Action Framework in practice: a citation analysis and systematic review. Implement Sci. 2014;9(1): Hudon A, Gervais MJ, Hunt M. The contribution of conceptual frameworks to knowledge translation interventions in physical therapy. Phys Ther. 2015;95: Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implementation science : IS. 2008;3: Sudsawad P. Knowledge translation: Introduction to models, strategies, and measures.. In: The Board of Regents of The University of Wisconsin System, ed. Austin, TX: Southwest Education Development Laboratory, National Center for Dissemination of Disability Research; Duncan EA, Murray J. The barriers and facilitators to routine outcome measurement by allied health professionals in practice: a systematic review. BMC Health Serv Res. 2012;12: Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implementation Science. 2012;7: Jones CA, Roop SC, Pohar SL, Albrecht L, Scott SD. Translating Knowledge in Rehabilitation: A Systematic Review. Physical Therapy Menon, Korner-Bitensky N, Kastner M, McKibbon KA, Straus SE. Strategies for rehabilitation professionals to move evidence-based knowledge into practice: a systematic review. Journal of Rehabilitation Medicine. 2009;41: Graham ID, Logan J, Harrison MB, et al. Lost in knowledge translation: time for a map? The Journal of continuing education in the health professions. 2006;26(1):13-24.

11 16. Salbach NM, Guilcher SJ, Jaglal SB. Physical therapists' perceptions and use of standardized assessments of walking ability post-stroke. J Rehabil Med. 2011;43(6): Pattison KM, Brooks D, Cameron JI, Salbach NM. Factors Influencing Physical Therapists' Use of Standardized Measures of Walking Capacity Poststroke Across the Care Continuum. Physical Therapy Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4: Colquhoun H, Michie S, Sales A, et al. Reporting and design elements of audit and feedback interventions: a secondary review. BMJ Qual Saf. 2017;26(1): Russell DJ, Rivard LM, Walter SD, et al. Using knowledge brokers to facilitate the uptake of pediatric measurement tools into clinical practice: a before-after intervention study. Implement Sci. 2010;5: Perry SB, Zeleznik H, Breisinger T. Supporting clinical practice behavior change among neurologic physical therapists: a case study in knowledge translation. JNPT. 2014;38(2): Moore JL, Raad J, Ehrlich-Jones L, Heinemann AW. Development and use of a knowledge translation tool: the rehabilitation measures database. Arch Phys Med Rehabil. 2014;95(1): Romney W, Salbach NM, Parrott JS, Deutsch JE. A knowledge translation intervention using audit and feedback and the Theoretical Domains Framework for physical therapists working in inpatient rehabilitation: a case report. Physiotherapy theory and practice. in press. 24. Leeman J, Calancie L, Hartman MA, et al. What strategies are used to build practitioners' capacity to implement community-based interventions and are they effective?: a systematic review. Implement Sci. 2015;10: Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From Theory to Intervention: Mapping Theoretically Derived Behavioural Determinants to Behaviour Change Techniques. Applied Psychology. 2008;57(4): Mowatt G, Grimshaw JM, Davis DA, Mazmanian PE. Getting evidence into practice: the work of the Cochrane Effective Practice and Organization of Care Group (EPOC). Journal of Continuing Education in the Health Professions. 2001;21(1): Straus SE, Tetroe J, Graham ID. Knowledge Translation in Health Care: Moving Evidence into Practice. 2nd Edition. UK: BMJ Books; Christensen C, Wessells D, Byars M, et al. The impact of a unique knowledge translation programme implemented in a large multisite paediatric hospital. J Eval Clin Pract. 2017;23(2): Lizarondo LM, Grimmer-Somers K, Kumar S, Crockett A. Does journal club membership improve research evidence uptake in different allied health disciplines: a pre-post study. BMC research notes. 2012;5: Moore JL, Carpenter J, Doyle AM, et al. Development, Implementation, and Use of a Process to Promote Knowledge Translation in Rehabilitation. Arch Phys Med Rehabil. 2018;99(1):82-90.

12 31. Schreiber J, Stern P, Marchetti G, Provident I. Strategies to promote evidence-based practice in pediatric physical therapy: a formative evaluation pilot project. Physical Therapy. 2009;89(9): Tilson J, Mickan S. Promoting physical therapists' of research evidence to inform clinical practice: part 1--theoretical foundation, evidence, and description of the PEAK program. BMC Med Edu. 2014;14: Bekkering GE, van Tulder MW, Hendriks EJ, et al. Implementation of clinical guidelines on physical therapy for patients with low back pain: randomized trial comparing patient outcomes after a standard and active implementation strategy. Physical therapy. 2005;85(6): Bernhardsson S, Larsson ME, Eggertsen R, et al. Evaluation of a tailored, multicomponent intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial. BMC health services research. 2014;14: Maas MJ, van der Wees PJ, Braam C, et al. An innovative peer assessment approach to enhance guideline adherence in physical therapy: single-masked, cluster-randomized controlled trial. Physical Therapy. 2015;95(4): Rebbeck T, Maher CG, Refshauge KM. Evaluating two implementation strategies for whiplash guidelines in physiotherapy: a cluster randomised trial. The Australian journal of physiotherapy. 2006;52(3): Salbach NM, Wood-Dauphinee S, Desrosiers J, et al. Facilitated interprofessional implementation of a physical rehabilitation guideline for stroke in inpatient settings: process evaluation of a cluster randomized trial. Implement Sci. 2017;12(1): Willems M, Schroder C, van der Weijden T, Post MW, Visser-Meily AM. Encouraging post-stroke patients to be active seems possible: results of an intervention study with knowledge brokers. Disabil Rehabil. 2016;38(17): Colquhoun HL, Lamontagne ME, Duncan EA, Fiander M, Champagne C, Grimshaw JM. A systematic review of interventions to increase the use of standardized outcome measures by rehabilitation professionals. Clin Rehabil. 2017;31(3): Kall I, Larsson ME, Bernhardsson S. Use of outcome measures improved after a tailored implementation in primary care physiotherapy: a prospective, controlled study. J Eval Clin Pract. 2016;22(5): Meerhoff GA, van Dulmen SA, Maas MJM, Heijblom K, Nijhuis-van der Sanden MWG, Van der Wees PJ. Development and Evaluation of an Implementation Strategy for Collecting Data in a National Registry and the Use of Patient-Reported Outcome Measures in Physical Therapist Practices: Quality Improvement Study. Phys Ther. 2017;97(8): Brown CJ, Gottschalk M, Van Ness PH, Fortinsky RH, Tinetti ME. Changes in physical therapy providers' use of fall prevention strategies following a multicomponent behavioral change intervention. Physical Therapy. 2005;85(5): Connell LA, McMahon NE, Redfern J, Watkins CL, Eng JJ. Development of a behaviour change intervention to increase upper limb exercise in stroke rehabilitation. Implement Sci. 2015;10:34.

13 44. Levac D, Glegg SM, Sveistrup H, et al. A knowledge translation intervention to enhance clinical application of a virtual reality system in stroke rehabilitation. BMC Health Serv Res. 2016;16(1): Nanninga CS, Postema K, Schonherr MC, van Twillert S, Lettinga AT. Combined clinical and home rehabilitation: case report of an integrated knowledge-to-action study in a Dutch rehabilitation stroke unit. Physical Therapy. 2015;95(4): Leavy B, Kwak L, Hagstromer M, Franzen E. Evaluation and implementation of highly challenging balance training in clinical practice for people with Parkinson's disease: protocol for the HiBalance effectiveness-implementation trial. BMC Neurol. 2017;17(1):27.