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Teaching Evidence Assimilation for Collaborative Health Care Capacity Building for Knowledge Based Improvement Peter Teaching Evidence Assimilation for Collaborative Health Care Capacity Building for Knowledge Based Improvement Peter Wyer MD Chair, Section on Evidence Based Health Care New York Academy of Medicine

TEACHING EVIDENCE ASSIMILATION FOR COLLABORATIVE HEALTHCARE ACKNOWLEDGEMENTS TEACH TEAM LIBRARIANS INTERNATIONAL ADVISORS NYAM TEAM TEACHING EVIDENCE ASSIMILATION FOR COLLABORATIVE HEALTHCARE ACKNOWLEDGEMENTS TEACH TEAM LIBRARIANS INTERNATIONAL ADVISORS NYAM TEAM Saadia Akhtar Louise Falzon Ian Graham Eileen Budd Barney Eskin Pat Gallagher Dave Davis Donna Fingerhut Eddy Lang Pattie Mongelia John Lavis Francine Leinhardt Judy Honig Dorice Vieira Sharon Straus Sharon Ching Aleksandr Tichter Jamie Graham Yngve Falck-Ytter Tawana Wright Suzana Alves Silva Yingting Zhang Arlene Smaldone Craig Umscheid TJ Jirasevijinda Stewart Wright Claudette Dykes-Brown

TEACHING EVIDENCE ASSIMILATION FOR COLLABORATIVE HEALTHCARE DISCLOSURES No Faculty Disclosures Declared Generous Donation of TEACHING EVIDENCE ASSIMILATION FOR COLLABORATIVE HEALTHCARE DISCLOSURES No Faculty Disclosures Declared Generous Donation of Electronic Resources: Annals of Internal Medicine (ACP Journal Club) BMJ Group (Clinical Evidence, Evidence Based Nursing) EBSCO (Dynamed, CINAHL) Mc. Graw-Hill-JAMA (JAMA Evidence) Wolters Kluwer (OVID, Up. To. Date)

Who Are We? The Section on Evidence Based Health Care at the New York Who Are We? The Section on Evidence Based Health Care at the New York Academy of Medicine

Objectives: Capacity Building • Patient centered care • Responsiveness to change • Knowledge based Objectives: Capacity Building • Patient centered care • Responsiveness to change • Knowledge based improvement

TEACHING (EVIDENCE ASSIMILATION) • Evidence Based Practice • Clinical Policies, Recommendations • Knowledge Translation/Implementation TEACHING (EVIDENCE ASSIMILATION) • Evidence Based Practice • Clinical Policies, Recommendations • Knowledge Translation/Implementation

TEACHING (EVIDENCE ASSIMILATION) • Evidence Based Practice • Individual patients • Clinical Policies, Recommendations TEACHING (EVIDENCE ASSIMILATION) • Evidence Based Practice • Individual patients • Clinical Policies, Recommendations • Populations • Knowledge Translation/Implementation • Systems

TEACHING (EVIDENCE ASSIMILATION) • Basic, or Foundational, Skills • Individual patients • Reviews, Appraising/adapting TEACHING (EVIDENCE ASSIMILATION) • Basic, or Foundational, Skills • Individual patients • Reviews, Appraising/adapting guidelines • Populations • Knowledge creation, implementation • Systems

TEACHING (EVIDENCE ASSIMILATION) • Basic, or Foundational, Skills LEVEL 1 • Reviews, Appraising/adapting guidelines TEACHING (EVIDENCE ASSIMILATION) • Basic, or Foundational, Skills LEVEL 1 • Reviews, Appraising/adapting guidelines LEVEL 2 • Knowledge creation, implementation LEVEL 3

Level 1 • Constructed priorities and preferences • Road Map defining evidence literacy • Level 1 • Constructed priorities and preferences • Road Map defining evidence literacy • Narrative, clinical and epidemiological skills

Level 2 • • • Clinical policies and recommendations Specific health care settings Guideline Level 2 • • • Clinical policies and recommendations Specific health care settings Guideline appraisal and adaptation The GRADE system Building in adaptability, actionability

Level 3 • • • Team based problem definition Gathering ‘internal’ + ‘external’ evidence Level 3 • • • Team based problem definition Gathering ‘internal’ + ‘external’ evidence Consider health services, implementation research Monitoring measurable and sustainable impact Maintaining currency

A Common Skill Matrix Across Dimensions • • • Problem delineation Formulating information needs A Common Skill Matrix Across Dimensions • • • Problem delineation Formulating information needs Finding the most relevant evidence Appraising evidence quality and importance Evaluating relevance, interpreting applicability Assimilation

(Teaching) Evidence Assimilation (Teaching) Evidence Assimilation

Evidence from research: Lead protagonist or supporting cast? • • Scientifically informed individualized care Evidence from research: Lead protagonist or supporting cast? • • Scientifically informed individualized care Evidence-informed clinical policies Knowledge-based quality improvement The narrative dimension

Scientifically Informed Clinical Practice Within Organized Health Care Settings Scientifically Informed Clinical Practice Within Organized Health Care Settings

Executive Management Individual patient care Clinical policy development Implementation Specialties Team Practitioners Care delivery Executive Management Individual patient care Clinical policy development Implementation Specialties Team Practitioners Care delivery Patients

The TEACH Experience DRIVERS Clinical/Administrative • • Problem driven Comprehensive team QI present, subordinated The TEACH Experience DRIVERS Clinical/Administrative • • Problem driven Comprehensive team QI present, subordinated Systematic approach – Lit review – Chart review – Baseline outcomes • 18 months to launch • Prize winning results Quality Improvement • • Intervention driven Limited team QI operationally in charge Shortcuts – Direct planning to implement – No baseline data • 6 months to launch • Modest results

Attributes “QI” • • • vs Process OC Error Variation Short turn around QI Attributes “QI” • • • vs Process OC Error Variation Short turn around QI team Industrial standards “KT” • • • Patient-centered OC Unnecessary care Innovation Intermediate turn around Organizational engagement Scientific standards

KT or QI KT or QI

Hence: EBM + QI ≠ KBI Hence: EBM + QI ≠ KBI

MODE Quality Improvement/TQM CONTENT Process Outcomes (Error reduction Variation decrease) Clinical Outcomes Knowledge Translation MODE Quality Improvement/TQM CONTENT Process Outcomes (Error reduction Variation decrease) Clinical Outcomes Knowledge Translation EXCHANGE Internal Knowledge External Knowledge (Adoption of innovation ‘De-adoption’ of unnecessary care) Nonaka: Organizational Kowledge Creation

Comparative Effectiveness and Practice Based Research: The Frontiers of “EBP” • The importance of Comparative Effectiveness and Practice Based Research: The Frontiers of “EBP” • The importance of local, or ‘internal’ evidence • The importance of practice experience • PBR-blurring the boundary between ‘research’ and ‘practice’ • Classical clinical research remains valuable, frequently crucial, but nontheless indirect